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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 /> License#: (03(O 31-7 Exp Date: 1 12,11 2-o1iDate: 10 Contractor: Pf FCA S 104 SA+M 0 L.4 AJ 6,�t1G. <br /> Signature: "'' Title: OWAA4I0�JS MA-tiJ,A6FK <br /> ' Print Name: 61ZFNbA' G4,4-WFUf-*b <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 /> X 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 carver and policy numbers are: <br /> Carrier:. Seth}o-',gh+ TiSultanw Policy Number: Q)6I 115W(.0 <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 p visions. <br /> Exp. Date:_ t0 1?JU�(?-- Signature: <br /> ' Print Name: 6AfoWDA CVLA-vJF- " <br /> ' WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AH 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ' 1, bkFfJ-DA C*Awf Oo (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) trin llfU , to sign this San Joaquin County Well S Boring Permit <br /> ' Application on my behalf. I understand this a horization is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> 1 <br />