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N <br /> San Joaquin County Environmental Health tlrepar:ment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> city a --Atoi . ,.r o,. t , r. ,nte, _ec . n . of 0. LeAurlil drid Vci.%t F1 nr a 1 t . <br /> rell <br /> JOB ADDRESS Stockton 5k Tr (Fe- uer ;Fittqt F ,.,,. . .,, . E,a F E :F ;NIIT SR # <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 Ic m- mencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my lic:tmSEI is in full force and effect. <br /> License #: Exp Date: ..- � lc��S � 17 Z1� ( 0L— <br /> Date: Contractor: l , � a��2ppr�eP�2 <br /> Signature• iTitle : _ <br /> Print Name: - - -. <br /> WORKERS' COMPENSATION DECLAMATION <br /> I hereby affirm under penalty of perjury one of the following declaratic • s (I.heck one) <br /> I have and will maintain a certificate of consent to self-in:>w'e for workers' compensation , as <br /> provided for by Section 3700 of the Labor Code, for the peroTrlance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, :3E n3quired by Section 3700 of the <br /> Labor Code, for the performance of the work `or which his permit is issued . My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrienat }j � i )os CA Policy Numb 3r: kon 2: I I — \LA <br /> 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 woi compensation law of California, <br /> and agree that if I should become subject to workers' compo - s A )n provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions . <br /> Exp. Date: I L N. F INS Signature: <br /> Print Name: .%Laf C <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA43E 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 SECTION 3706 UI ' THE: LABOR CODE , <br /> AUTHO RATION FOR gTHtR THAN C-5i SIGNINO IF RMIT APPLICATION <br /> /! <br /> (signature of C-5 iIi :ensed authorized representative), <br /> rebYAuthorize (print name) to sign this San „ Equin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid fol cine year and is limited to the work <br /> plan dated on the front page of this application . <br /> EHD 2901 05/09/12 WELL PERMIT APP <br />