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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FJOBADDRESS: I(A ( o In R4 > ) v HCl l I S t ��*�RMIT 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 4fullrceand effect. <br /> License #: `7� Exp Date: <br /> Date: _ Contractor. <br /> Signature: Title: <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 /> have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> abor Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: r <br /> Carrier:%yl�h!JChAI u-J.1, 1--,41 V Policy Number: ( t�� 1 q�3dC rt <br /> I certify that in the performance of the work for which this permit is issued, 1 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 provisions. <br /> Exp. Date:�� ��I `i6 Signature: <br /> Print Name: a_ i r+ <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 9706 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) 611 N 1 >s L 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 /> END29-01 OE W12 WELL PERM"APP <br />