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y <br /> WELL PERMIT APP <br /> EHD 29-01 07/20/10 <br /> San Joaquin County Environmen:al Health Department <br /> WELL & BORING PERMIT APPLI(:ATION SUPPLEMENTAL <br /> JOB ADDRESS: 515 west Charter way, Stockton 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 Business and Professions Code and my license is in full force and effect. <br /> 4 <br /> License #: L� � �� Exp Date: K\oA , ?� I iu6 - <br /> Date: Contractor. A VvQ\ <br /> Signature: Title: <br /> — <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 /> 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 number:. are: <br /> Carrier. 'j���\ 4� Policy Number: 1� —�-- <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' ccmpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: ( . 2 \ Signature: _ <br /> Print Name:_ '11�P1'� • ����C 1t <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 3706 OF THE LABOR CODE. <br /> AUTHORIZATI OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> i �y a Daniel Villanueva to <br /> herebori print name) <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 /> WELL.PERFAIT APP <br /> EHD 29-01 01f20110 <br />