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San Joaquin County Environmental Health Cii:par,:ment <br /> WELL &c BORING PERMIT ,APPLICATION S1.1PPLEMENTAL <br /> 230 N Church St,Lodi,CA 95240 <br /> JOB ADDRESS; F 41WIT SR# <br /> LICENSED CONTRACTORS DECLARATION {LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter 0 Ic)r-mencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my licrmse is in full force and effect. <br /> License#: t""`"��t ��� exp Date: <br /> Date: I—(A C `1i Contractor: Alt <br /> Signature: W Title:_ i " <br /> Print Name: , .... <br /> WORKERS' COMPENSATION DECLA':?ATI JN <br /> I hereby affirm under penalty of perjury one of the following deelaratiorls: (1:heck one) <br /> I have and will maintain a certificate of consent to self-ir:u•e for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pe'o-mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, a: required by Section 3700 of the <br /> Labor Code, for the performance of the work for which ilii:; Kermit is issued. My workers' <br /> compensation insurance carrier and policy numbe-s are: <br /> Carrier; S�A�_ w s� Policy Nur, <br /> I certify that in the performance of the work for which this pe rrrit is issued, I shall not employ any <br /> person in any manner so as to become subject to the wor• ars' compensation law of California, <br /> and agree that if I should become subject to workers' compE °s st :)n provisions of Section 3700 of <br /> the Labor Cade, I shall forthwith comply with those provision <br /> Exp. Date: Signature: <br /> Signature; <br /> Print Name; <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA3E IS UNLAVs'U„:',ND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION 1 1^ IFI-11' COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 C?-1 HE. LABOR CODE. <br /> AUTHO ? DTHER THAN C-57SIGNIN(i PERMIT APPLICATION <br /> (signature of C-a" licensed authorized representative), <br /> heteby orize(pri name) to sign this San Jwig11in County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid fc • <anq year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APF' <br /> EHD 29-61 WWI 12 <br />