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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _73Q 6. C H--01 n i S PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm► thatll�amrGcensed 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 #: 72-Q Q Exp Date: 9/34/ IL( <br /> Date: � ffu Contractor: 1/ � pr,`���i� ; <br /> Signature: `Title: <br /> Print Name: )4 41' <br /> WORKERS' COMPENSATION DECLARATION`` <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) � — <br /> 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 rwhich-0-4s-6pe;:T:pis. issued ; <br /> compensation`insurance carrier and policy numbers are: . - t <br /> j Carrier: �► ��cm�I�ns47 .LnsWr�-1�Fk4JPolicy Number: JQ�6 57Z/I � F <br /> I certify that in the performance•of the work for which this p t is issued, I shall not employ any <br /> person in any manner so as to become subject to the w rkers' ompensatio w of California, <br /> and agree that if I should become subject to workers' corn ensatio provisions of ection 3700 of <br /> the Labor Code, shall forthwith comply with those provisio <br /> Exp. Date: Signature: , <br /> <� <br /> V� <br /> Print Name: <br /> WARNING: FAILU TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRI A4�ES� C FINES UP T041100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> r t A O SAS PROVIDED FOR INS ECTION 3706 OF THE LABOR CODE. <br /> UT RIZATION FOR O HER THAN C-57 SIGNING PERMIT APPLICATION <br /> 4 <br /> I, k (signature of,C-57 licensed authorized representative), <br /> x hereby auth�rjze (pr t name)\ i 1 G ,4Z , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 'I understand this authorization is valid.for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHO29-M 05109/12 WELL PERMIT APP <br /> 4 <br />