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ih <br /> 1 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 75d 6. CH wn01 e rr-,e--e,f—, PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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 #: 7Z0LT Q Exp Date: 4?1,304q! <br /> Date: �Z Contractor: V`�'�✓P�t`�lI« <br /> Signature: r Title:L YJ <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 numbers are: <br /> Carrier:.!�t-ar< <am4Jens41;,'ng TAS-ti r.­^ e_Fu,1dPolicyNumber: YLI <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' com ensatio provisio sof ection 3700 of <br /> the Labor Code, shall forthwith comply with those provisio <br /> Exp. Date: Signature: )A <br /> Print Name: l I <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 /> A O EY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �UT RIZATION F�ROHERTHAN 6-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> x hereby auth ze (pr t name) i h - 4. 4.0 , 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 /> END 29-01 05109112 WELL PERMIT APP <br /> i <br />