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San Joaquin County Environmeital Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR # <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'Cal'ifornia Business and Professions Codi:and my license is in full force and effect.. <br /> l 5 <br /> License#: _� r+� Cl I Exp Date: <br /> Date: )(3t Contractor: _r <br /> Print Name: <br /> WORKERS' COMPENSATIC N 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 /> I have and will maintain workers' compensation nsurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work tar which this permit is issued. My workers' <br /> compensation insurance carrier <br /> ;and policy number s are. <br /> r Carrier: SAUt -E Policy Number: <br /> I certify that in the performance of the work for wt-ich this permit is issued, I shall not employ any <br /> person-in any manner so as to become subject t: the workers' compensation law of California, <br /> and agree that if I should become subject to work(.rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. .� <br /> Exp. Date: _ C` J ZL Signature: 4 <br /> -Print Name:_ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES7AND:DAMAGES AS PROVIDED FOR IN SEC TION 3706 OF THE LABOR CODE. <br /> --AUTHORdZATION„F,pR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ignatule of C-57 licensed authorized representative), <br /> hereby authorize(print name) , 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 /> EHD29-GI 07128n0 + WELL PERMIT APP ' <br /> 1 v <br /> r <br />