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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 500 East Louise Ave., Lathrop, CA PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />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 #: t _if )t�— E Date: <br />r <br />Date: \ Z' Contractor: va <br />Signature: -�-��„•'\ I 't��, ; � `, �,� \ Title: � <br />Print Na <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 />have and will maintain workers' compensation insurance a <br />--�- p s required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compen ion insur ce car and policy numbers are: <br />n ► <br />i <br />'� r- �7)� <br />Carrier: 1! i ( Put..,y :Jurnber: <br />certify that in the performance of the work for which this permit is issued, I shall not em <br />ppy any <br />person in any manner so as to become subject to the workers' compensation law of Ca ifor ia, <br />and agree that if I should become subject to workers' compensation provisio s of,bection X3700 of <br />the Lab o Cod' , I shall forthwith comply with those � rovisions. � <br />Exp. Date: 1 <br />\" Signature: �i.•i ��-�; � ��I ,� <br />Print Name: 1`! 4( �� �f .�f >� I vl/ �A <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMI)LOYER TC <br />CRIM INAL PENACTIFS AND .CNIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORS FEES, A D DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />t RUTH RIZATIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of <br />� , C-57 licensed authorized representative), <br />hereby aut orze (p int nam "�,kICA ) I„.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 />EHD 29-01 05/09/12 <br />WELL PERMIT APP <br />