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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> P(.4141,F,Ca- <br /> JOB A DDRESS: W• \/o S 6M f T o� 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 #: E xp Date: os - <br /> Date: _ C Contractor: \i f 0 n4.y <br /> Signature: I Title: Of_� CYlCtf1C,�C,el� <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 insurance carrier an d policy numbers are: <br /> Carrier: rJZs` Policy Number: aDq 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 to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pravis' s. <br /> Exp. Date: �:� Signature: <br /> Print Name:�' �� DCtmGnfi <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 FO(R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I cx (signature of C-67 licensed authorized representative), <br /> hereby authlize(print name)QIUf► C,)Urchi 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 /> WELL PERMrr APP <br /> E HD 2'S.01 07W I0 <br />