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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: i ' 1�� V \IA I��1I 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 California Business and Professions Code and my license i in full force and effect. <br /> License#: 1 Exp Date: H <br /> Date: , I contractor: I A��l (l l l�!� 14 - <br /> Signature- . Title: �� Ilv, <br /> Print Name: t V `L YU Vl <br /> WORKERS' COMPENSAT N 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 foC which this permit is issued. My workers' <br /> compensat n ins Iur'a�nce mer andpolicypolicy numbers are: 1 J ' ! <br /> Carrier: � ;n(-- \ Policy Number: 01�J / l "I' ��I� <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' com ensation law of California, <br /> and agree that if I should become subject to workers' compensation r visions of S�ction 3700 of <br /> the Labor Code, I shall forthwith comply with those pr)Islons. <br /> Exp. Date: I Signature: '�'J <br /> Print Name: t )0 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUB 7 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, / DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UT RIZATIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ^I (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I 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 /> EHD Z9-0t OS/09I12 WELL PEWITAPP <br />