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+ EHD 29-01 07/20/10 • WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL HSC a <br /> BORING PERMIT APPLICATION SUPPLEMENTAL <br /> S <br /> E b1IIcffi OYL O Y\ Cka-✓yc kn st, <br /> JOB ADDRESS: I e+A w p o � Da&A �n Sf- 4- �°Ce(il}7tl PERMIT SR# <br /> &fi <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 Business and Professions Code and my license is in full force and effeceffect.License#: C`5�- �IpC(� Exp Date:: 2-�O-1 a W <br /> Date: a0�� Contractor: DYljl(MQ <br /> Signature: Title: C14� <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 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 <br /> � p/� <br /> numbers are: <br /> Carrier: Stak bl' oprlS(�1 t JOS, I WCC Policy Number: I Vi7Z43�3- <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisionJ�-�/ <br /> Exp. Date: 7//a L0 Signature: <br /> Print Name: 4-"P..4e~ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <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 3706 OF THE LABOR CODE. <br /> ,AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> 4 hereby authorize(print name) f�L Lia Iyjak✓z ,to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EH0 2901 07120110 WELL PERMIT APP <br />