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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: M0 Qoum)�) s Rw&\ QYW 'u s g52Ill0PERMIT SR# <br /> � <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 Is In full force and effect. <br /> License#: `105QL Exp Date: Nac1 3111013 <br /> Date: 12 IZ7 112 Contractor: J;yCw rx <br /> Signature: APA010 --- Title: 90ma- <br /> PrintName: NYIShQInra �U11S <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> X 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy Number: <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' 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 provisions. <br /> Exp.Date: 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$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST. <br /> ATTORNEY`S FEES,AND DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Appllcatlon on my behalf. 1 understand this authorization Is valid for one year and Is limited to the work <br /> plan dated on the front page of this appllcatlon. <br /> EHD2"1 2"1 05%1 z WELL PER aT APP <br />