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San Joaquin County Environm.•ntal Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 340 Newton Road <br /> PERMIT SR# <br /> LICENSED CONTRACTOR` DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cod= and my license is in full force and effect. <br /> License#: (\ —Exp Date: I('1`1)� I l 1 <br /> Date: -�A ` ( � �_T \'L Contractor: ,�� �► �� ��! 1 1( � 111114 i l <br /> Signature: Title: �t f ,0(!-I 4 <br /> Print Name:_ <br /> WORKERS'COMPENSATIC N DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc 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 /> X _I have and will maintain workers' compensation i Isurance, as required bySection 3700 of <br /> Labor Code, for the performance of the work for which this permit is isthe <br /> sued. My workers' <br /> compensation insurance carrier and policy number: are: <br /> Carrier:L-�(]-�c To �L1 P alicy Number: <br /> 0­1Z 111 - \� <br /> I certify that in the performance of the work for whi,:h this permit is issued, I shall not employ any <br /> person in any manner so as to become subject tc the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those I Irovisions- <br /> Exp. Date: �2A 1 1 ) j ,1 Signature: <br /> Print Name:_ (j e\n J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIININAL PENALTIES AND CIVIL FINES UP To $1o0,000, IN ADDITION To THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECT fON 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 c IGNING PERMIT APPLICATION <br /> -_- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to sign tl is 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 01/13111 <br /> WELL PERMIT APP <br />