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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 4�40 W' L 1)'1 L •_J v ����V J PERMIT SR# <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 orce and effect. <br /> License#: 3 Exp Date: b11 <br /> Date: ��� _ Contractor: <br /> Signature: �/i--,/ ILIUM <br /> may-�—, -I-�-/-. Title: r� Q /�r <br /> Print Name:��� 5 !7T ! G(.L"'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: + ,/y <br /> Carrier-A i l �nILkWl �>� n_.r0 Policy Number. L) -9_3'g3� <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,.l shall forthwith comply with those provisions. <br /> Exp. Date: ��� aG�5 Signature: <br /> Print Name: . 7 A 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 $700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, - / `-- (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 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 /> ER022o1 05m9112 <br /> WELL PERMIT APP <br />