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San Joaquin County Environmental Health IN p:lrtment <br /> WELL & BORING PERMIT APPLICATION J'f'LEMENTAL <br /> JOB ADDRESS: 701 East Charter Way ' 'E R10IT SR# <br /> LICENSED CONTRACTORS DECL,.JZATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 1 (:c,nmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cody and my I ::en,;e is in full force and <br /> -effect. <br /> License#: �� Exp Date: ,�:)� <br /> Date: ( c. ` � \ �( � Contractor: <br /> Signature: Title: _ `�SL11. (L'LL <br /> Print Name:" 4 ._Ii< -- <br /> WORKERS' COMPENSATION DECO RATION <br /> I hereby affirm under penalty of perjury one of the following declarati::n (check one) <br /> I have and will maintain a certificate of consent to self-i 3urc for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code. for the p •for-nance 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 h s permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: ,\( '� t \ ` \ \( Policy Nui she <br /> I certify that in the performance of the work for which this p::rrii-. is issued, I shall not employ any <br /> person in any manner so as to become subject to the wog".ers' compensation law of California, <br /> and agree that if I should become subject to workers' comp-isalion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisior <br /> Exp. Date: ! 1 ', �� Signature: <br /> Print Name:,._+_; <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA3E IS UNLAV =LL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION I ) TF1= COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 :;F rF=LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGN IW: 13FRMIT APPLICATION <br /> (Signature of C-51' I cimsed authorized representative), <br /> hereby au6orize rint name) DanelV la%eva to sign this San .o3cluin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid V r ore year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 07128110 WELL PERMIT APP <br />