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1./ Vol, <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: a)o3 J z°1cs n' �, fin« ��vc 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#: G.�7 � --�� Exp Date: <br /> Date:__._ �•!� Contractor. <br /> Signature: Title: <br /> j <br /> Print Name:_ e2a-- +Pf 61AC <br /> •a <br /> qyb Rbwf toad <br /> lam)31� c1Arc Ob WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) cF ,f <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 /> 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 /> CarrierNr Policy Policy Number: /5;yel <br /> , <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 Californipl <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 provisio . PIS <br /> Exp. Date: S/ f �� Signature: <br /> Print Name: / /'Y/llE'/'— }' <br /> • ,F�rS• <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER-10- <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 3708 OF THE LABOR CODE. -.- <br /> U RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION 01y <br /> 1 (signature of C-57 licensed authorized representatiV4 <br /> hereby authorize(print name) to sign this San Joaquin County Well & boring Pei!A <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the WON. <br /> plan dated on the front page of this application. ----- <br /> 6Mo 2%01 05raa12 WELL PERMI I XPP <br /> :.r c <br /> T'O- <br /> ,.-gT, <br />