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San Joaquin County Environmental Health flop ar:ment <br /> WELL & BORING PERMIT APPLICATION S'JPPL.EMENTAL <br /> JOB ADDRESS : U rci et' h-r-w -a S 1 F14RN1IT SR # <br /> i <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 icornmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my li(:a:ns(! is in full force and effect. <br /> License #: 7 } �7�� _ =xp Date: \ -non a , <br /> Date: ' �C4r1� ContractorAi . � tL. V # � tln ( . <br /> Signalure: Title : <br /> .- <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratic is (i.heck one) <br /> _ I have and will maintain a certificate of consent to self-ir < u e for workerscompensation, as <br /> provided for by Section 3700 of the Labor Code, for the per o -mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance , )< squired by Section 3700 of the <br /> Labor Code, for the performance of the work for which ibis permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: 7 <br /> Carrier: LM a Y\ A PolicyNuritbrr: YI l �,� i ` ` <br /> 1 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 worl ; or ; compensation law of California, <br /> and agree that if I should become subject to workers' compE s itl3n provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provision <br /> Exp. Date : Uhl- <br /> )hl- Signature - ar <br /> Print Name : <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TI; 1HE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 (it THE: LABOR CODE. <br /> AUTHORIZATION OTHER THAN C-57 SIGNINt F RMIT APPLICATION <br /> I "� %� (signature of C-51 li .ensed authorized representative), <br /> hereby aut#rSriza (print name) N��n�stgn this San .. 2equin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid for (m ) year and is limited to the work <br /> plan dated on the front page of this application. <br /> EK0 204)1 05/00112 WELL PERMIT APP <br />