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ii <br /> g . <br /> to/ <br /> NOW, <br /> 2 5 <br /> t <br /> t <br /> E San Joaquln County 1=nvironmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �� �� C�"rc�' � 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 California Business and Professions Code and my license is in full force and effect. <br /> License#: - � ���z-� Exp Date: <br /> I , / <br /> Date: 2 Contractor: <br /> , <br /> i <br /> Signature: =!G <br /> Print Name: <br /> r <br /> WORKERS'COMPENSATION DECLARATION I _ .f <br /> --i-hereby-affirm-under-penalty-of perjury-one.of the-following-declarations:..(cheek_one). y <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 <br /> I have and :will maintain workers' compensation insurance, as required by Section 3700 of the F <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 /> c�,� � --- y ccv �o <br /> Carrier: Policy Number: <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any f <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 .ode, I shall forthwith comply with those pr Irl i ns. <br /> Exp. Date: I� Signature: <br /> Print Name:� `✓ I`"v��i'7,�'`' ___ <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 /> T• FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 6fil-,� P�Kr , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 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 /> EMD 2"1 05!09/12. WELL PERMIT APP <br />