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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL. <br /> JOB ADDRESS: 2203 J-2-2 cr —JI-4 i M-" '4'/ nr-' PERMIT SR# <br /> encs cF�c. J IfLJ c�I�J �arulJ (JLC a��incl pc:vni�J) <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: f Contractor: <br /> Signature: Title: G 'a'? <br /> s <br /> i Print Name: <br /> tl15 NbWC 1�asc1i <br /> c1A WORKERS' COMPENSATION DECLARATION r <br /> (92ti) 31�i_ygav , <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) .0 of <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 tYiis " <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of tl ie <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: of" 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 Californigl <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 provlsio as <br /> Exp. Date: <br /> , Signature• <br /> Print Name: c�l/�`i' <br /> Kars <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE ADDITION TOUTHE D SH OF SUBJECT <br /> N EMPLOYER--To- <br /> CRIMINAL <br /> MP OYER--T <br /> CRIMINAL PENALTIES AND CIVIL FINES UP To S9oo, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. :�^ <br /> AU RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION r�Y <br /> I (signature of C-57 licensed authorized representatiV,�)r <br /> hereby authorize(print name) cik,,/sf,nt-cc , to sign this San Joaquin County Well & Boring PAA ; <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the wwk <br /> plan dated on the front page of this application. <br /> Wnl h�Xtlf APP ' <br /> EHP29-07 OSW12 �,�'r'r)• :. <br /> • .S_r <br />