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I <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: v qd• V �'� <br /> K/� PERMIT SR# . <br /> Und e.til <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'n full force and effect. <br /> 22 <br /> License #: 39/5,-7o E xp Date: c� v�®®� <br /> Date: Contractor: 1"T)IU L()I1SU/1 LO. �/1!C <br /> T <br /> Signature: Title: .rr6 Vx1r,%10 t*%J <br /> Print Name: >t�►Co�AS �UNEZ I <br /> I <br /> WORKERS' COMPENSATION DECLARATION I <br /> P <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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.af the <br /> Labor�Code; 1for the performance of the work for which this permit is issued. My workers`" <br /> compensafion insurance carrier an d policy numbers are: 3 <br /> IanJn5uraaae, Polic Number: —oa <br /> Carrier:A'II. � _ y <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' mpensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pro isi ns. <br /> Exp. Date: �! 8/ �`® Signature: �• <br /> Print Name: N.cA b Ac. Ae e(. <br /> M <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (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. 1 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 /> i <br /> WELL PERMR APP <br /> EHD 29-01 07//2x/10 i <br /> f <br />