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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: L-16vy V `-'f�,V— 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 Californian Business and Professions Code and my licen`s 'is in fu I force and effect. <br /> License#: Exp Date: <br /> Date: I �! ontractor: <br /> � <br /> Signature: (,1 Title: <br /> Print Name: <br /> WORKERS'COM SATION 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 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 /> compensa' insurance ca yer and polic numbers are: 225,, 1 ' I <br /> Carrier: <br /> i Policy Number:�0�t-l�35 — <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 to the workers' pensation law f California, <br /> and agree that if I should become subject to workers'compensation p ovlsions 'f Se tion 3700 of <br /> the Labor Code, I shall forthwith comply with those provi ions, <br /> Exp_Date: � I Signature; <br /> 1 <br /> Print Name• ✓ I I rl) P7 IAI <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUB CT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMS AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A H ZATION FOOTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i r V II rr ((rnature of C-57 licensed authorized representative), <br /> hereby authorize(print name) KI b [d COrsign 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 /> EHD 29-01 M9112 WELL FEFWJT APP <br />