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Dec 11 12 10:52a R 8 p•2 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> II II 1^ n '�1 <br /> JOB ADDRESS: L 13Z-; t I I I I /tC�w1�J L I-+ PERMIT SR# <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License# C_ -'�`�[�'7 Exp Date: l ' 114 <br /> Date: it 11 Contractor:�7t> 1 -x:,-•1LJ <br /> Signature: Titl P�� <br /> Print Name r A 1 n'V r.A it iNQ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 /> -LI/I have and will maintain workers' compensation insurance, 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 insure ce carrier and policy numbers are: <br /> As'�I-�o�3c3— 1 <br /> Camey: 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, <br /> and agree that if I should become subject to ork ' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with t se p visi <br /> Exp. Date: Signature: �. <br /> Print Name:. I�.''1 pro i <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER 70 <br /> CRIMINAL PENALTIES AND CML FINES UP TO 8100,000,IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROV+DED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> � ►� ` <br /> 1 (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) J1 d0. 4A; , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 115-M12 WELL PERWT APP <br />