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i w� <br /> San Joaquin County Environmental Health Department7(LC-D) <br /> " <br /> WELL&BORING PERMIT APPLICATION SUPPLEME <br /> JOB ADDRESS: '108 .,d 211cs 6J �' 14C)4 brivt PERMIT SR <br /> cn� cF�t .,vrrv�:,di,.� rcr:clJ (JtC c;��J�ncl Pcw,i��> <br /> LICENSED CONTRACTORS DECLARATIO <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#: C5-7 Yk! ,/ Exp Date: <br /> Date: Contractor: � ��/ <br /> Signature: Title: <br /> Print Name: I9'U/l0� <br /> q�b RD10 aad <br /> QM�d�i}t VVp-z,. C/A WORKERS' COMPENSATION DECLARATION i <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) csr I <br /> •'1 <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 thiT <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of fhe <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: Re-, Policy Number: 119/ W©10 �l ~ <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 workers'compensation provisions of Section 3700 <br /> the Labor Cade, I shall forthwith comply with those provisio . as <br /> Exp. Date: l�� Signature: <br /> Print Name: <br /> WARNING=FAILURE TO SECURE WORKERS'COMPENSATION CRIMINAL P NALTI S AND CIVIL FINES UP TO$100,000,�IN ADDITION TOGE IS UTHE COST OF COMPENSL,AND SHALL SUBJECT ATION, INTEREST, <br /> ATTORNEY'S ME$,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> U RI 11TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION ny <br /> l (signature of C-67 licensed authorized representatiy�; <br /> hereby authorize(print name) Si,r�t ci+�„/tk�kc , to sign this San Joaquin County Well & boring Per)mi1 <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the wrack' <br /> plan dated on the front page of this application. ----- <br /> EHOR9.Ot OSIOtY12 WELLPE��^�1'APP <br /> gl 4 <br />