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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION 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 California Business and Professions Code and my license is in full force and effect. <br /> G� � r .) \ <br /> License# `LA( L C IV1=xp Date: i / l ``�C <br /> Date: 1� \ Contractor: I, �\ \yC\\ (v�('�a Y af�C�l�f ►l� <br /> Signature: 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 /> xI 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, <br /> and policy numbers are: <br /> Carrier: -vXA "y-1 �C� Policy Number: <br /> 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 /> anj 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 provisions. <br /> Exp. Date 1 ) \ — \ Signature: _ l <br /> Print Name:_ ; <br /> J <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAC:E 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 /> ATTORNEYS FEES,-AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION€O THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signatu-�e of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Applicatior 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 29-01 01113111 WELL PERMIT APP <br />