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EHD 29-01 07/20/10 WELL PERMITAPP <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 800 W.Church Street.Stockton.CA 95203 PERMIT SR# <br /> r <br /> " I <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 /> License#: C-57 485-165 Ftp Date: 31 January 2013 <br /> nate, . 17 Tuly 2012 Contractor, Grope DJ*Uine <br /> Signature: Title: <br /> Print Name: Cl 1 <br /> WORKERS'COMPENSATION DECLARATION 7 <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 /> X 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: WOW,) <br /> Carrier: Policy Number: Oy/GWOW,) W/O0 <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'compensation provisions of Section 3700 of the <br /> Labor Code, I sh 11 forthwith comply with those provisions oe <br /> Exp. Date- l Signature- <br /> Print Name: <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 /> ORI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Tony Smith s to <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 /> EHD 2&01 07120110 WELL PERMIT APP <br />