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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOIE ADDRESS: ------- -- - PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LCCA) <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 />i. <br />License #: C5 7 '�1�;' l._f _ Exp Date: <br />Date' / ..; Cortiact, r % F �,c. <br />Signature: T. 1, <br />Print Name: -i -'�:: 1 tj.��r-� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check ane) <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, :;s required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. Idly workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: i`, i C <br />—�i;.i Policy Number: flt�66.%C:�`r�G, I %S 2 <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: Signature: <br />Print Narne: (,'':/2./ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIM NAL PENALTIES AND Civil- FINES UP TO $1,00,000, IN ADDITION TO THE CeOST OF COMPENSATION, INTEREST, <br />,:-,.-,ATTORNEY'S FEES, AND -DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />-APTF OAZA 'ICN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensers authorized representative), <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 />EliD29-01 G5r09112 <br />WELL PERdIT APP <br />