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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: L ,,-,fl , C-1 CM WIC-I d r1 Hl ?-Z� 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 Califomia Business and Professions Code and my license 's in full,force and effect. <br /> GSC — <br /> License 4. 1�— Exp Date: I L <br /> Date: niractar: <br /> �� �� Id )� � _ �► lel (�� � '� <br /> 1 � <br /> Signature: i. "i I '� Title: <br /> Print Name: <br /> WORKERS' COMPENSATION 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 /> A—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 /> compensatl�n insurance rier and policy numbers are: <br /> Carrier: �, �� 'C y Policy Number: � �r'� �1 i.� <br /> L A <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' comps sajon law of Cal ornia, <br /> and agree that if I should become subject to workers' compensation pr vislo4�hs of Section 700 of <br /> the Labor de, I hall f rthwith comply with those provi ions. <br /> i 1 i <br /> Exp. Date: Signature: <br /> 14 <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 FEES,AND DAMAGESASPROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO TION FOR OYHER THAN C-57 SIGNING PERMIT APPLICATION <br /> V (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) �t! .� i! 1/ , 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. L� <br /> Enb 29A7 0�709r2 WELL PERMIT AFP <br />