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San Joaquin County Environmental Health Department <br /> /WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ' D 1d' QA � S PERMIT SR # <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 /> License#: <br /> rr cxp Date: <br /> Date: r)12`� 1 Z Contractor: Wal <br /> l,. <br /> Signature: <br /> Title: _ F \�fY)+ <br /> Print Name: (7i-)e y <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 /> 1 have and will maintain workers' compensation nsurance, 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 number s are: <br /> Carrier: j nt 7y )(-)CA Policy Number: )EJ 7- <br /> 1 <br /> 1 certify that in the performance of the work for wtich this permit is issued, I shall not employ any <br /> person in any manner so as to become subject !o the workers' compensation law of California, <br /> and agree that if I should become subject to work-:ars' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Dated — - 7 j'>� Z Signature: <br /> Print Name:_. <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA(:E IS UNLAWFUL,ANDSHALL 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 /> (signature of C-57 licensed authorized representative), <br /> s� <br /> hereby authorize(print name) Tim Cuellar <br /> to sign this San Joaquin County Well & Boring Permit <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 /> EH029. 1 07 a&10 <br /> WELL PERMIT APP <br />