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San Joaquin County <br /> Environmental Health Department <br /> F <br /> ELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ESS: Q9 <br /> D �,}. aF 'w� PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> of the California Business and Professions Code and my license is in full force and effect. <br /> �r t '�- xpDate:1,24\•I 1Z _ Contractor: _Title:: >t� \.e: � <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followincl declarations: (check one) <br /> I have and will a e of <br /> as <br /> provided t for by Secon13700 oflthe tloself-insure <br /> Labor Code, for theperformance of the workpfor which this <br /> permit is issued. as <br /> Section <br /> 0 of the <br /> I have and will maintain <br /> erfor workers' <br /> cof pensation nsurance,work for which th s rperm'tdis tissued. MyOworkers' <br /> Labor Code, for the p <br /> compensation insurance carrier and policy numbers are: <br /> 1_C* \�1� Policy Number: o l l , \ — \\- 2-- <br /> Carrier: <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 10 the workers' compensation law of California, <br /> and agreeCodef I hall should <br /> become <br /> comply with hos prows o ensation provisions of Section 3700 of <br /> the <br /> Exp. Date: 17 1 L\Z Signature:; <br /> Print Name:_ <br /> r-. <br /> TION <br /> CE IS <br /> FULAND SHALL SUBJECT AN <br /> LOYER TO <br /> WARNING:CFAILURE TO SECURE WORKERS'RIMINAL PENALTIES AND CIVIL FINES 5700,OO�IN ADDITION 4TO 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 /> (signature of C-57 licensed authorized representative), <br /> I, <br /> Tim Cuellar to sign this San Joaquin County Well & Boring Permit <br /> hereby authorize (print name) <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 /> WELL PERMIT APP <br /> Etl029-01 D7a&10 <br />