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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 3)"42, 2 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 #: qy 5,11 !�- Exp Date: L I3 % <br />t 1 n I -A- <br />Date: 1 3�- f �0 i I. Q Contractor �� .. � ,1.Y t t L. t' &e -x <br />Sign <br />Print <br />Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I <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 and policy numbers are: <br />Carrier: �£Ctv/ Policy Number: I;s 1 1602tv_ <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 Califomia, <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 provisi s. <br />Exp. Date: IAll Signature: <br />Print Name: 1 VlS(ls" i�►� \�" uYl�-' <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 />RI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I> (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 />EHD 29-01 07128/10 <br />WELL PERMIT APP <br />