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EHD 29-01 07/20/10 ( i� WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ,;j r 6 :2t' S+-i 11 , 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 Business and Professions Code and my license is in full force and effect. <br /> r /� <br /> License A (.l� Exp Date: <br /> , <br /> Date:_. Q'A Contractor:��r^ a a <br /> Signature: /� f Tide: 1 <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> y 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:_- � i !l �s Policy Number: /"r"/�C / 100 <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,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:_ Signature: <br /> [__.� Signature• ;Y <br /> Print Name: -- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML 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 /> AUTHORIZATION FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> X:)1, ) (signature of C-57 licensed authorized representative), <br /> hereby author rmt name) - e c, ,to <br /> sign this San Joaquin County Well&Boring Permit Application on behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 23DI 07/20/10 - WELL PFRWT APP <br />