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Nwe wo, <br /> i' <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2,)oa J 19cs 6J. f57--mi , Noir D6111 PERMIT SR# <br /> cn� cF�c �vrry✓:,Jir�.� �aar:clJ <br /> (JL( c�iJ�ncl pt•-.�ni��> 7 <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#: CS7 ��f-�f Exp Date: <br /> Date: Contractor: g2 S2 � 9, <br /> Signature: Title: <br /> Print Name: <br /> qt b J�awe load <br /> Mar},nezWORKERS' COMPI=NSATION DECLARATION s <br /> l4Z�i) 1�goti <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) cT <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 alis-- <br /> permit is issued. <br /> I have and well maintain workers compensation ensation insurance, as required by Section 3700 of the I <br /> p <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:_ GO'0,1�Qe 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 Californi�,l <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 .. as <br /> iii? .... ' <br /> Exp. Date: -� Signature: l'a`",�— _... <br /> Print Name: <br /> WARNING:FAILURCRIMINAL PENALTIES ANDTO SECURE CIVILFINMPENSATION ES UP TO$100,000,IIN ADDITION TOGE IS UTHE COST OF COMPENSATION,D SHALL SUBJECT P INTEREST, <br /> REST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> U RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION -Iny <br /> I (signature of C-57 licensed authorized representativ4 <br /> hereby authorize(print name) to sign this San Joaquin County Well & Boring Pe' nil <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the wpfk` <br /> plan dated on the front page of this application. ----- <br /> EHD240f pY0G�12 MLLPEl1lT`APP <br /> :.' <br /> -S't, <br />