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• <br /> San Joaquin County Environmental Health Department <br /> WELL & BORINGPERMITAPPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I uV o w . uA..jrg tr 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 <br /> California Business and Professions Code and my license is in full force and effect. <br /> License#: (7 `�� Exp Date: I()I Y-A �Z <br /> Date: FIContractor. _ t-A\1 OC'11 i��C(lYY� I1(�_I11(1 <br /> Signature: <br /> Title: <br /> Print Name: (>,n— -- <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 consen: 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 numbers are: <br /> Carrier: y -6 _ Policy Number: <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 work,:lrs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name:_. a�— <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 /> (signature of C-57 licensed authorized representative), <br /> s <br /> hereby authorize(print name) Tim Cuellar 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 /> WELL PERMIT APP <br /> EHD 29-01 07128F10 <br />