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EHD 26-01 07120110 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: `:1. . lQ _��ZJI�IOR Lt__��� Z_EPERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my li:ense is in full force and effect. <br /> License#,: UJ _xp Date: U-- <br /> Date: 1 Contractor: i <br /> Signature: ^� Title:__ Y P��1CPf'l <br /> Print Name:� ��P <br /> WORKERS' COMPENSATI(;)N DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin{:1 declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I <br /> I have and will maintain workers' compensation in:urance, as required by Section 3700 Of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> 1 <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to-the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:,] 1 1 X12 _ _ Signature: <br /> Print Name:, _Y'� <br /> r <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'$FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AVTHORI O.. OR OTHER THAN C-5'7 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), ; <br /> hereby authorize(print name). ,to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 2991 07rM14 <br /> WELL PERMIT APP <br />