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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 34701 S• Welty Road. Vernalis, CA 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#: `1 �' i `i Exp Date: _�� =/I <br /> Date: 'hII L Contractor. <br /> -T <br /> Signature: _ Title: <br /> Print Name: -^ t ; <br /> 'v <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 /> >` 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: C-4 ,kc-- IF:-- '.1 . � Policy Number: �� �` � - <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 provisions. <br /> Exp. Date: l ' 1 I l Signature: ��--- <br /> Print Name: '��_ ^— n,�' <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000, 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 /> AUTHOR ZATION F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name S,- to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand is authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> VVELL PERMIT AFP <br /> EHD 29-01 05109x12 <br />