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WELL <br /> San Joaquin County Environmental Health pe <br /> ✓HELL BORING PERMIT APPLICATION SUPPLEMENTAL <br /> partment <br /> JOB ADDRESS: <br /> LICENSED PERMIT SR # <br /> CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the `L�LD <br /> ) <br /> Division 3 of the California Business and Professions Code and m <br /> provisions of Chapter . (commencing With Section 7000) of <br /> License#: y license is in full force <br /> and effect. <br /> Date: Exp Date: <br /> Contractor: <br /> Signature: <br /> Title: <br /> Print Name: <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 sett 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 /> 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. 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 beccme subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwkh comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COIPENSATiON COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINS UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES APROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OVER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understarthis authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this appition. <br /> WELL PERMIT APP <br /> EHD28-01 D5,M12 <br />