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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />LICENSED CONTRACTORS A'A <br />(LCD) <br />I hereby affirm that I arh 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 affect. <br />License #: <br />/ 0 !7Exp Date: 011 _q//, -2e <br />Date. �/ •3/ r% Contractor. <br />Signature: , Title: _ 016y1= , <br />Print Name:: <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 forworkers' 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 and policy numbers are: <br />Jq <br />CarrierAdSar. :ro- A e✓v�i 6t � � ! �/1/,,-_ ELf7.7022 Z <br />'j�'/! oI cy Ntl b r' =� <br />1 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 provisions.: <br />Exp. Dates —S Igria tu rel <br />Print Narric <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION covERAGE IS UNLAWFUL„ AND SHALL SUBJECT AN r=MPLOVER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP. TO $400;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 />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) , 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 />29-01 07128!10 <br />way PeWTAPP <br />