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EHD 2&01 07020;ID • WELL PERIVAT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Mwit N\c 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 /> Divisidn 3 of the Business and Professions Code and my license is in full f rce a d effect. <br /> License#: 1{ _ E p ate: <br /> Date: Contractor: v j <br /> Signature: _ ` 1 Title: <br /> Print Name: <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 ins ranc arneraj d policy numbers are: i J�/�I , I <br /> Carrier: % `� Policy Number: I �- D?W l.( T 11. <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' co salion law of California, and <br /> agree that if I should become subject to workers' compensation p ovisi ns of Section 3700 of the <br /> Labor Co /I/ all forthwith comply with those provi i S. p <br /> Exp. Date: Y� I� Signature: V `" <br /> Print Name: (' fi1-6 1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL E 1 .1 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 AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> RI ATI N OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, /l ignature of C-57 licensed authorized representative), <br /> hereby authorize (print name) O ,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 /> FRU 9 G1 V4 410 'n'1L <br />