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41 <br /> + I t ►..! <br /> EHO 29.01 07;20:W L <br /> '/JELL PEPf.IT APP <br /> San Joaquin County EnvironmEntal Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL " # <br /> 4 - <br /> ' r <br /> JOB ADDRESS: 7—%A107. _ �acl4tr.... PERMIT SR # r 0I a" ' <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 Business and Professions Code and my license is in full force and effect. <br /> 1 License#: f 'i =xp Date: i E � �;� � �(-•1 Z- <br /> Date: I i 1.} Contraclor: �_.a �;( ;I t� `( ( i �.,',..'�• , 14- <br /> Signature: Titfe: <br /> S :a- <br /> )print Name - i } _ `p <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (cheek 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 have and will maintain workers' compensation insi,irance, as required by Section 3700 of the M <br /> Labor Code, for the performance of the work for.which this permit is issued. Myworkers' <br /> compensation insurance carrier and policy number:; are: <br /> � <br /> rt <br /> Carrier: � f1`;' Policy <br /> I certify that in the perforniance of the work for whit-) this permit is issued. I shall not employ any T <br /> person in any manner so as to become subject to the workers' compensation Iav�of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, 1 shall forthwith comply with those pro%,isions. <br /> Exp. Date: ,�_j_ �1 <br /> Signature: <br /> Print Name:_ <br /> WARNING: FAILURE TO SECURE WQRKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CPEMINAL PEN4L'TIES AND CIVIL FINES UP TO$100.000,IN ADEATION TO THE COST OF COMPENSATION,INTEREST, <br /> yrso ...�_,...- . � <br /> Lhereby <br /> TORNEY'S FEES;A77D DAMAGES AS PROVIDED FOR IN SEC'"ION 3706 OF THE LABOR C_ODE;W <br /> UTHORIZATION FQ��]THER THAN C-57 SIG�i�IG'PERN[I'T'4APPC7]CATION <br /> (signatun: of C-57 licensed authorizedrepresentative),orize 4�Y{prEnt name) ` 1 � ` C, to <br /> n Joaquin County Welt & Borirr)g Permit Applicatir.�n on my hehalf. .l understand this aufflorization <br /> o ar'and is limited to the work plan.dated on t le front page of-this application. <br /> teto,4, <br />