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San Joaquin County Environm:mtal Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: "cherotetA'sto' <br />PERMIT SR # <br />LICENSED CONTRACTOR`S 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 #: _f( j T�- �� Exp Date: <br />Date: �� `\ I T - Contractor:., Ill �k o 01 <br />Signature: Title: _ 4 t , 0A l4 <br />Print Name: "�. X-1 S `�. �.Y r.I r <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 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' <br />compensation insurance carrier and policy number:: are: <br />Carrier:Policy Number: J1j - �\ - <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 workers' compensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those Iirovisions. <br />Exp. Date: LI I ILL — <br />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 ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECI'ON 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 : IGNING PERMIT APPLICATION <br />-- -- (signature of C-57 licensed authorized representative), <br />iereby authorize (print name) WIIIII-L"110 to sign this San Joaquin County Well & Boring Permit <br />\pplication on my behalf. I understand this authorization is valid for one year and is limited to the work <br />Ilan dated on the front page of this application. <br />EHD ?P-01 01/13/11 <br />WELL PERMIT APP <br />