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I.-001 u <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADDRESS: �t10 Wcord S+. PERMIT S <br /> //�1 R <br /> # <br /> I C" 1 C pA- <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 /> License#: (o3(0 32-7 Exp Date: l'3 l i 2014 <br /> Date: �Ia1 I�-- Contractor: PIQEGSIVNI S0MDL.4N6 111G. <br /> Signature: _ Title: OPEq-Wi1171JS MA-RJ.A15,Et4 <br /> Print Name: e31zFlibA- c4c"Fole-Z <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 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 /> X 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:_ a5l kaV1(,Q Policy Number. &)11159X0(4 <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 pr visions. <br /> Exp.Date:_ to 1,5 L l a-= Signature: Q_l <br /> Print Name: 6"-JJDA CO-A AJF&" <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 /> 11 6REI IVA C*44WF019 A �slgnature of C-57 licensed authorized representative), <br /> hereby authorize(print name) I Q o sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this But orization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 07nWIP WELL PERMIT APP <br />