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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT /APPLICATION SUPPLEMENTAL <br />Quality Cleaners, Tracy Corners Shopping Center <br />JOB ADDRESS: 3081 North Tracy 131vd, Tracy, CA 95376 PERMIT SR # <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 in full force and effect. <br />License #: C-57 # 695970 Exp Date: 71so/ ac It. <br />Date: t ? r' zG % !74 Contractor: j&l v. L� N %�ZOL <br />/ <br />Signature: �-, k Title: t' S <br />Print Name: <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 />v I have and will maintain workers' compensation insurance, 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 numbers are: <br />Carrier: 5T47 C FU Policy Number: % �7" Z G %(o ` 2y 14 <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 />�� <br />Exp. Date: 5-13 Zo( S Signature: <br />+ Print Name: �iT✓rlc�� <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,004), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, -_ <br />QRY&Y4A6G&, AMD DMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) f lfc.%%Ji5 6 110 L" -a_ , 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 />EHID if, 01 05.0') 12 <br />WELL Pf_HI,;IT AFP <br />