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San Joaquin County Environm mtal Health Department <br />WELL & BORING PERMIT APPL ICATION SUPPLEMENTAL <br />JOB ADDRESS: WATERLOO ROAD, STOCKTON <br /> PERMIT SR # <br />LICENSED CONTRACTORE DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Cod and my license is in full force and effect. <br />License #: (6445--Pi Exp Date: IC .1'1)\ 2 ( ,1 <br />Date: 1 ( 1E11_ Contractor \dui )11411+ <br />Signature: Title: --A t on <br />Print Name: <br />WORKERS' COMPENSATICN DECLARATION <br />I hereby affirm under penalty of perjury one of the followinc 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 I isurance, as required by Section 3700 of the <br />Labor Code for the performance of the work for which this permit is issued My workers' compensation insurance carrier and policy number! are <br />Carrier: 1 -1 (1 Pdlicy Number: <br />I certify that in the performance of the work for whi :h this permit is issued. I shall not employ any <br />person in any manner so as to become subject tc the workers' compensation law of California. <br />and agree that if I should become subject to workeis' compensation provisions of Section 3700 of <br />the Labor Code. I shall forthwith comply with thosei.rovisions. <br />Exp. Date: Signature: <br />Print Name: <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 A )DITION TO THE COST OF COMPENSATION. INTEREST. <br />ATTORNEY'S FEES. AND DAMAGES AS PROVIDED FOR IN SEC1 ON 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 E IGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) William Little <br />, to sign tf is 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 01/13/11