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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#: Exp Date: 1 <br /> Date: Contractor: . <br /> Signa, <br /> Title: <br /> Print Name: l °� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty erjury one of the following declarations: (check one) <br /> I have and will maintain certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 370 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' mpensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance o the work for which this permit is issued. My workers' <br /> compensation insurance carrier and poi y numbers are: <br /> Carrier: 14f)k-4, Policy Number: <br /> I certify that in the performance of the work r which this permit is issued, I shall not employ any <br /> person in any manner so as to become subj ct to the workers' compensation law of California, <br /> and agree that if I should become subject to w rkers' compensation provisions of Section 3700 of <br /> the tabor Code, I shall forthwith comply with t o provisions. <br /> Exp. Date: 10 2 1 Signature: <br /> Print Name: Ue <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 /> AT - IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I ,` (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)J UG I`t�V?A0 , 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 /> EHE 29-01 01713/11 WELL PERMIT APP <br />