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:E <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 429 W.Yosemite Avenue PERMIT SR # <br /> Project site address: 420 W.Yosemite Avenue <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 <br /> 1California <br /> /Business and Professions Code and my license s in full force and effect. — <br /> License #: 7 /�� Exp�D^ate: <br /> Date: O / Contractor: <br /> Signature: ��t Title: <br /> Print Name: U� �/atl- <br /> WORKERS' COMPENSATION DECLARATION i[p <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) j <br /> 9 <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: ZgLz 7` Policy Number:l2ec,&VInflo 0 I° <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' compensatio provisions of Section 3700 of <br /> the Labor Code, I sh II forthwith comply with those provisio S. <br /> Exp. Date: Signature: <br /> Print Name: 19611Por <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 /> i <br /> i <br /> RIZ --3 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of G57 licensed authorized representative), ° <br /> �t <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 /> t <br /> EHD 29-01 05109/12 <br /> WELL PERMIT APP <br />