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* • <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> K•WJ?-vAr <br /> JOB ADDRESS: 1-1-1-1 W• \/o S fz M 1 T X AVE 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 is in full force and effect. <br /> License#: —705q Al E xp Date': 05 - 3I ' I t <br /> Date: \ <br /> Contractor: ' V k,V,O nC)e <br /> Signature: Title: Q7� rzt mgmQerc <br /> Print Name: 1�{ �(� �>layyyo-i <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 an d policy numbers are: <br /> Carrier: \ Policy Number: aD%4 V <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 t0 workers' compensation provisions of Section 3700 of <br /> the Labor Code, 1 shall forthwith comply with those provis' S. <br /> Exp. Date: 3A Signature: , ,., <br /> Wg- <br /> Print Name: Pto- h�mQL-,fi <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 /> AUTHOR ATION�FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-67 licensed authorized representative), <br /> hereby au.:T.-.---(print name)Ia`C1n Cllufcki i 11, 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 /> EHO 29.01 07/8'10 V*LL PERMIT APP <br />