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...Y 3 1�ty" '.. Fr�P. 4 '{•A'F.LI PE maT A Ne�� <br /> SIi'r <br /> San Joaquin County Environmental Health Department <br /> FWELL Sc BORING PERMIT APPLICATION SUPPLEMENTAL �'���rrt, fes.jr�..�f'` 4�f� <br /> - i <br /> JOB ADDRESS: Z%Aa-L PERMIT SR #' <br /> S-6 <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 : =xp Date: I I ,}' 'z t <br /> �=- ..; <br /> Date: :l } <br /> 1 CoITt1-actor- � �' l <br /> Signature: - x <br /> Title` <br /> Print Name: <br /> 4 WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of.perjury one of the followincl 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 o0he 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 wf,ich this permit is issued' My workers' <br /> compensation insurance carrier and policy number:: are: <br /> Ca rrier:�._.y�i-��[ - <br /> Policy Number: <br /> I certify.that.in the performance of the work for whit i 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 proOsions. <br /> Exp. Date: Si <br /> �G– "`�� �• <br /> �--- gnature: <br /> Print Nafne: '` 1 <br /> . <br /> WARNING-FAILURE-TQ SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,ANDSHALLSUBJECT AN EMPLOYER TO <br /> CRIMINAL'PENALTIES AND CIVIL FINES UP TO$100.000.IN ADIATION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC'_rON­3706 OF THE LABOR CODE.. <br /> AUTHORIZATION.,,,—QTHER THAN C-57 SIGNING PERMIT-APPLICATION r ! f <br /> ri . � (signature of C-57 licensed authorized representative), <br /> hereby.authorize (pant name) `�,� - _ .� j \1` <br /> to <br /> sign this San Joaquin County Well &� Boring Permit Applicati,:m on my behalf, ! understand Ehis authorization <br /> is valid for one year and is limited to the work plan dated on t ie front page of this application. <br /> r'HO 29-C1 07.4,nG • •. <br /> FCL'Fq!'T t__ <br />