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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMITAPPLICATION SUPPLEMENTAL <br /> Joe ADDRESS: ,,-jl(-jtil �� m I ,� ;�Y RLA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION QCD) <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 fu)l force and effect. <br /> License#: 91'3 6 Exp Date. 31 >l6 <br /> Date: Contractor. PtJP <br /> Signature: �i'' n� �Z'----Title: <br /> Print Name: ti K�� ►te=a i <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 370D of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 1 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. y� <br /> Carrler,A4tL&Im .fai1a tJJWAt9 Policy Number: LA- R �3 I <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 1 should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Cod I shall forthwith comply With those provisions. <br /> Exp. Date: Signature:Print Name:[/g 1.5 1J <br /> tA <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 7706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) j � , to sign this San Joaquin County Wall & 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 /> WELL PERAUT APP <br /> ENO <br /> 2041 05109/12 <br />