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�C T r <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I/D Al, SoctLA Ylnnr St, 1-Mf: CA PERMIT SR 4 � S <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 Code and my license is in full force and effect <br /> (P1 g1t9 Ex Date: -S 112013 <br /> License f=: p <br /> Date: [(a 12m Contractor: eG��►I�ICOi�{ CVI��v1e�(tVIc�S�'rl/I�S,�K. <br /> Signature: Title: <br /> Print Name: `DarYewIyl l-, IcLmS <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(Keck 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 /> 1 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; 1 rO Ve,krs Policy Number: Ul g1v_�57R q8 _ <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 Califomia, <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: Q! I I l 2 Signature: <br /> Print Name: �arf�n �►.tt)I l l�� m 5 <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 IN SECTION 3706 OF THE LABOR CODE. <br /> 17ati2 G- �V� vlrvL S (signature of C-57 licensed authorized representative),.,_____.___._.______ <br /> here authorize(print na �e to sign this San Joaquin County Well & Boring Permit.. <br /> t <br /> Application on my behalf. 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 /> ~• „ £m-.,Ot O7h8710 1Nr1L PERhIr APF <br />