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San Joaquin County Environmental Health D:partment <br /> WELL & BORING PERMIT APPLVCATION V;UPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (cc: n-noncing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my I :else is in full force and effect. <br /> Contractor Name: FM \ LAA lk VACAo(m_".V* .___. <br /> License#: �� _Expirati:)n Date:N�kDAber IST <br /> Signature: _Title:—ijp, -r <br /> Print Name: _Date: ;f- 1T�c� <br /> WORKERS' COMPENSATION DECLARA,' 10111 <br /> I hereby affirm under penalty of perjury one of the following declarations: ch(:ck one) <br /> I have and will maintain a certificate of consent to self-insure x workers' compensation, as <br /> 13 provided for by Section 3700 of the Labor Code, for the perfc -mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, a:; re quired by Section 3700 of the <br /> Labor Code, for the performance of the work for which this pc: niit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> s� <br /> Carrier: yuV6 Policy#: �QIZ1 I I_ IExp. Date:Ue-, I IS <br /> I certify that in the performance of the work for which this permit is issue:d, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation lave of California, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3730 of the Labor Code, I shall <br /> forthwith comply with those provision:: <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA31:: IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, �,770RNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Ll gT-V iL: k hereby authorize -i Ln,iat <br /> �, xa pL:ui <br /> to sign this San Joaquin County Well & Boring Permit Application on riy behalf. I understand this <br /> authorization is valid for one year and is limited to the work pl"ted only front page of this application. <br /> n <br />