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�rrlcr�e <br /> San Joaquin County Environmental Health I)cp;:rtment <br /> WELL & BORING PERMIT APPL CATION c J 'F LEMENTAL <br /> JOB ADDRESS: 500 East Louise Ave •ER'AIT SR # <br /> LICENSED CONTRACTORS DECLf%FATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter V (corTmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Ii:::ris:1 is in full force and effect. <br /> License#: � .1���n Exp Date: �5:� _ l <br /> Date: ��(AF + " � Uj �T Contractor. 1 U(._u-1AL0 Jf)rlf�'� <br /> Signature: !%j/�%/� Title: S �C.IPhI <br /> Print Name: <br /> WORKERS' COMPENSATION DECLAI;An')N <br /> I hereby affirm under penalty of perjury one of the following declaratic -s (;:heck one) <br /> _1 have and will maintain a certificate of consent to self-in:,Jre for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the peI fDim,)nce of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, =s rl:quired by Section 3700 of the <br /> Labor Code, for the performance of the work for which t'lis permit is issued. My workers' <br /> compensation insurance carrier and policy number.3 are: <br /> Carrier::C,1�)n d Policy Number: <br /> I certify that in the performance of the work for which this peirii, is issued, I shall not employ any <br /> person in any manner so as to become subject to the work:!-s' (:ompensation law of California, <br /> and agree that if I should become subject to workers' comper axion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply With those provisions. j <br /> Exp. Date:aL 1 1 � i <br /> ?$�'� ` 111 �Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE: IS UNLAWF. . AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO "'H= ::OST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF 'H:LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING OE R MIT APPLICATION <br /> (signature of C-57 :e m ed authorized representative), <br /> hereby authoriz"rintname) William Little <br /> , to sign this San Jc q A i County Well 8 Boring Permit <br /> Application on my behalf. I understand this authorization is valid for :na year and is limited to the work <br /> plan dated on the front page of this application. <br /> EIiD 2V-01 OSgftl5 -_ <br /> WELL PERMIT PPP <br />