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t � <br /> San Joaquin County Environmental H'ealthbLedUnt nt Cdk. <br /> WELL & BORING PERMIT APPLICA1@l5 , UF?J1ylffgf4, *red Without <br /> .{{,,O being COmPieted or inspac`,d <br /> Harney Locust <br /> JOB ADDRESS: <br /> HL & Tree Road,Lodi by W1T18M . : ,,� !fit � <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 /> 499908 EX <br /> License#: P Date: 10/31/2016 <br /> Date: <br /> �b '`5 Contractor: Krazan&Associates,Inc. <br /> Signature: <br /> Title: Managing Engineer <br /> Print Name: David R.Jarosz <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 /> x 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: Travelers Property Casualty Company Policy Number: PJUB3F83999415 <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 /> Exp. Date: 01/01/2016 Signature: <br /> Print Name: Dave Jarosz <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 TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l (signature of C-57 licensed authorized representative), <br /> hereby a horiz print name) Dave Jarosz , to sign this San Joaquin County Well & Boring Permit <br /> Applic tion 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 05/09112 WELL PERMIT APP <br />