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0 9 /J(/ dw <br /> �`" WELL PERMIT APP <br /> END 29-01 071=10 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPL CATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 icense is in full force and effect. <br /> License#: <br /> 1 Exp Date: ?)1 <br /> Date: ],l '1 1 7 Cl\� Contractor. M l 11 Al lrtYlr itx l 111 <br /> Signature: <br /> Print Name: ) <br /> WORKERS' COMPENSATI)N DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin I declarations: (check one) <br /> _I have and will maintain a certificate of consent to >elf-insure for workers'compensation, as <br /> provided for by Section 3700 of the Labor Code,fi Ir the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation in::urance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for w Tich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbe s are: <br /> Carrier. \} 1 l 3olicy Number: \— <br /> I certify that in the performance of the work for whish this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to :he workers'compensation law of California, and <br /> agree that 11 should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pa visions. <br /> Exp. Date: Signature: <br /> ,—� —� ,—/ — <br /> Print Name:_ YG <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAC E IS UNLAWFUL,AND SHALL SUBJECT ANE PLOVER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN A)DITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SE TION 7706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-5' SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) e-( \i, ,to <br /> sign this San Joaquin County Well&Boring Permit Applica ion on my behalf. 1 understand this authorization <br /> is valid for one year and is limited to the work plan dated or the front page of this application. <br /> WELL PERMIT PPV <br /> ENDZ 072d10 <br />