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EHD 29-01 07/20110 <br /> WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> The intersection o= 1st St and C St, and <br /> JOB ADDRESS: the intersection of Folk St and SJagtail Dr 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 /> License#: 10lPI:z19 Exp Date: _ 1► �L i� <br /> Date: Li 1 17— Contractor: �n . <br /> vti.✓. <br /> Signature: l/� ;���� Title: Ci:D <br /> Print Name: '1Q 6 n 1n ti J C,-1 <br /> J � <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 /> • 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 /> i7�177 3 j -2v►1 <br /> Carrier: srak. For�,A Policy Number: <br /> 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:_ `SI I f Z 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 IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> k)u1 ,rJ In (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) AfV1 g- , to <br /> sign this San Joaquin County Well & Boring Permit Application on my 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 29.01 07!20/10 <br /> WELL PERMIT APP <br />