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San Joaquin County EnvironmsMai Health 0"rtment <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <br /> C.EC+v ) un- r7 <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#: fo3{v 519-7 Exp Date: ► a i 1.012 <br /> Date: )�11 Contractor:._ G S I�a S0M 0 N N bj ►iJG. _ <br /> Signature: Title: oWAA-n(?NS NA4JA6EFK <br /> Print Name: �QFN�pr Gr�A-1��L� <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 /> CoMpa*Jl0.&l flwo Lry C�PGA- 109XP <br /> Carrier•._AnJb CAIS/ _ PolicyNumber: <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 of <br /> the Labor Code, I shall forthwith comply with those pvisions. <br /> Exp. Date: fa 3 o Lv 1 I Signature: <br /> Print Name: AVt )DA C*,4WF't'0 <br /> wARNING:FAILURE TO SECURE WORKERT COMPENSATION COVERAGE IS UNLAVMX-AND!SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FUZES UP TO $100,000, IN ADomON TO THE COST OF COMPENSATION. INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN sEC71oN voe OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, baFOVA C",Vvfv" (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behaH. I understand this a orization is valid for one year and is limited to the work <br /> plan dated on the front page of this applkation. <br /> [sic s9-o+ m�au+a <br /> WaL VEMOT,ion <br /> CP '` CendCWI - EA P,+ \ Tel;In ,,I <br />