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San Joaquin County Environmental Health Department <br /> WELL & BORING1 PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: IS te� y .S4vck-�m• PERMIT SR # <br /> G� <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 force and effect. <br /> License#: 05970 Exp Date: wsol 14 <br /> Date: f3 Contractor: E,7 v, 6,-,f/c, C AsSLY_ , TxL64 <br /> Signature: Title: 7-.c4 <br /> Print Name: t/ <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: <br /> Carrier: `Y}TE F--tJ/V b Policy Number: 19 72096-13 <br /> 1 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, I shall forthwith comply with those provisions. <br /> Exp. Date: s1,31l¢ Signature: L--, <br /> Print Name: 1Lr✓1x;w <br /> 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$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I, J !�'! ,;/(— /y� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)$RrAN rrl•-A&TA;W, 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 /> EHD]P01 OSOP'tr <br /> WFLL FFflMII AGp <br />