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NOI111 CtQ1 0-'70.'10 .. . <br /> WELL PEFAIR APP <br /> .y lfw <br /> San Joaquin County Enviromnental Health Department <br /> WELL & BORING+PERMIT APPLICATION SUPPLEMENTAL <br /> V ilt <br /> JOB ADDRESS: ZLIcZ PERMIT SR # fi ;fl <br /> 5- <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 /> License #: r <br /> exp Date: <br /> Contractor: <br /> Signature,- _ Title �, <br /> Print Name: -- - i` �, €., <br /> l I r <br /> AL <br /> WORKERS' COMPENSATION DECLARATION <br /> l her affirm under penalty of perjury one of the following declarations: (check one) a <br /> I have and will maintain a certificate of consent to c;elf-insure far workers' compensation, as rt <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 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 insurance carrier and policy number are: <br /> . Carrier j N U 1 W 1� <br /> _ Policy umber: <br /> 1sj —_ - <br /> ' <br /> I certify that in the performance of the work for whic-1 this permit is issued..I shat! not employ any - <br /> -. person in any manner so as to become subject to the workers' compensation law of California. and ' Y <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 pro%.isions. <br /> ?� <br /> Exp. Date: G [-, Signature: =- <br /> Print Name:_ )� �.' .} t_ C <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,'"AND RISHALL SUBJECT AlN EMPLOYER TO <br /> CMINAL PENALTIES kND'CIViL FINES UP TO 3700.000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> " A�QIWEX.'.SIEEES,�AND-DAMAGES AS PROVIDED FOR IN 5EC"ION 3705 OF,TH J, CODE <br /> ALTMORIZATION FQE OTHER THAN C-57 SIGNING-PE-RW9T OlPtl°CATION <br /> (signature; of C-57 licensed authorized representative), <br /> herebyauthorize � _ _-`C � <br /> {print name) ✓"��� _ <br /> to <br /> sign this San Joaquin County Well & Boring Permit Appiicatfrm on my behalf- I understand this authorization - <br /> is valid for one year and is limited to the work plan dated on t'Ie front page of this application. <br /> EHD Mot <br /> k <br />