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San Joaquin County Environme ital 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/California Business and Professions Codl� and my license is in full force and effect. <br /> License#: �' r r Exp Date: Q 1j [' f <br /> Date: C `� 1�Ll,';ontractor:l E } <br /> Signature_ --- c - ---"Tit e _.�YS I CX <br /> Print Name: J t�— <br /> WORKERS' COMPENSATIC N DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin(€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 and policy number s are: <br /> ^{ _ <br /> Carrier: al± L='�-2 .)Y �W ,,,,•,, Policy Number: 1 c <br /> - "1- <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject 0 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: I Z e' 10\3 a Signature: -- <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 5700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ----- fsignatw a 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 /> pian dated on the front page of this application. <br /> EHD 28-01 0712&10 WELL PERMIT APP <br />