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0 <br /> WELL PERMIT APP <br /> EHD 2x01 07/20110 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5WC*VrL-Q-L)� iS-1-Zxao -)I eW PERMIT SIR# <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 effect. <br /> S 3 <br /> License#: (p (,P Exp Date: f 6 I3 1 /Z6 z <br /> l <br /> Date: <br /> /7 Z O 1 'Z- Contractor: ��`�r C'bt 4( F•� <br /> Signs 1 Title: j- Aecr�^outs 11Tavt.�4� <br /> Print Name: KL''h h e 1q g COO 1';� <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: 14 11'-dLc e-j 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 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 provisions. <br /> Exp. Date: 16/(� 1Z6 l z Signatur <br /> Print Name: P0• Coo A, <br /> WARNING: COVERAGEFAILURE TO SECURE WORKERS'COMPENSATION <br /> CRIMINAL P NA TES AND CIVIL FINES UP TO$100,00.NADDITIONLDSHALL <br /> TO THE COST OFCOMPENSA COMPENSATION, TO <br /> INTEREST, <br /> EMPLOYER <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOR17ATI <br /> /OJ/�1 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 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 /> weu PERMrt APv <br /> EHo 28-01 071=10 <br />