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San Joaquin County Environmental Health Department <br /> WEL,�L99& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Ire-tM C&>5-Y L7LI (tNi r 666 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 Ps in full_tCn��IV/pTa1US1 I(�tY �71 <br /> yytJlrce an <br /> d eff <br /> ect.oILicense#: pD <br /> DaContractor: VIA, <br /> I , —,, <br /> SigeatTitle: <br /> Print N <br /> WORKERS' COMP SATION 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 rrier and p r <br /> icy numbers are: <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which thispermit is ' ued, shall not employ any <br /> person in any manner so as to become subject to the workers' ompens ion law f California, <br /> and agree that if I should become subject to workers' compensa n provisi ns of Se tion 3700 of <br /> the Labor C de, I Shall forthwith comply with those rov'sions. <br /> Exp. Date: � � Signature: <br /> Print Name: ✓I <br /> WARNING:FAIL SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND• LL SUBJECT AN�[r PLOYER TO <br /> CRI IN., NALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> A ORNEY'S EES,AICIDD AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A HOR ION F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I +((signature of C-57 licensed authorized representative), <br /> hereby aut orize (p 'nt na 6T RlMtA1 to sign this San Joaquin County Well & Boring Permit <br /> Applicatio on my b half. 1 understand this authorization is valid for one year and is limited to the work <br /> PIE n dated on t- ont page of this application. <br /> EHD 2M1 05/08112 WELL PERMIT APP <br />