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San Joaquin County Environmental Health llopar :ment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS k " _„ ` F. ,.,._ . .,,:. F ERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 Icnn' mencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iic:: !nSE: is in full force and effect. <br /> I � <br /> License #l: e u\ � Exp Date : . .. 1(, ) <br /> Date: / �C� �� Contractor: <br /> Signature: ✓%moi-== Title : 11— <br /> Print Name: �� �Q� A - - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratic ' is (check one) <br /> I have and will maintain a certificate of consent to self-in :: u e for workers' compensation , as <br /> provided for by Section 3700 of the Labor Code, for the pero -mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, 3s required by Section 3700 of the <br /> Labor Code, for the performance of the work '`or which lhir hermit is issued . My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrierst z-P 1 VA (i Policy Numb �r: 71 I — <br /> I certify that in the performance of the work for which this pE mit is issued , I shall not employ any <br /> person in any manner so as to become subject to the worll , :r3' compensation law of California , <br /> and agree that if I should become subject to workers' compe - s )ti•)n provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> it <br /> Exp. Date : Signature: <br /> Print Name : . l, ] 'P, )/� ��QGI Y <br /> WAR4NG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAW PUL ., AND SHALL SUBJECT AN EMPLOYER TO <br /> ' 4tLRIN AL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TC THE: COST OF COMPENSATION, INTEREST, <br /> tn..✓ . ATTORNEY+SFEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OI ' IHEd LABOR CODE , <br /> AUTHORIZATION-FOR-OTHER THAN C=57SIGNING F E RMIT APPLICATION <br /> it <br /> (signature of CSili :ensed authorized representative), <br /> /. <br /> ht`!reby,adthorize:(prfnt name) ° - °""- , to sign this San ., )Egl.lin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid fcn on P. year and is limited to the work <br /> plan dated on the front page of this application . <br /> EHD 29-01 05109/12 WELL PEPMITAPP <br />