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CIO <br /> San Joaquin County Environrrir=utat Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL - <br /> JOB ADDRESS: ! 1 S36 A7. C—tfN7 MILE eoPr�l PERMIT SR 4 <br /> LICENSED CONTRACTORS DECLARATION (LCD)` <br /> hereby affitm that I am I;censed under the provisions of Chapter 9 (commencing with Section 7060) of <br /> derision 3 of the California Business and Professlons Code and my licanso is in full force and erect, <br /> License : 4tb r t Fxp Oate; 110 <br /> Data: Contractor. <br /> ` 1 <br /> Slgnalure; i Title: V P e.e <br /> Print Ware:, nip (.I1 ; t_L� <br /> WORKERS' COtv(i?� ATtON, DECLARATION <br /> If hereby affirm under penalty of periury one ofthe following declaration's: (check oho) <br /> _ 1 have and will maintain o eeriiticate of consent to self insure for workers' Compensation, as <br /> provided for by Section 3700 of the Labor Coria, (or the performance of the tirork for which this <br /> par nit is issued <br /> I <br /> I have and will maintain workers' compensation insuranoo, as required by Sectien '370b OHM <br /> Labor Code, for he performance of the work fpr which iris permR is lssLied. _My warkors' <br /> eonipertsa1 19 tion insurance carrier and policy numbafs are: <br /> Carriar: �r� •' � t ^ in rn. rs PolfeyNumbar, �' ��{ {.`3' �a'�101 . <br /> I certify that in the performance of the-work for 4yhich this permit is Issued, I shalt no(,employ any <br /> person in any manner so as to become, subject in tho wo versk compensation taw iii Oatifornia <br /> and agree that itI should became subject to workers Compensation prdv1 9 i! ns of Seption 3700 of <br /> the Labor Co&, t, $!tell fordivrlttl rerrtpiy with those proVisions <br /> Exp, L1afe: ' t � r t t Signature ; 'l <br /> Or, <br /> tit Namei ; i:T> <br /> 3VARi#RG1 FAILURE 7e SECURE WORKERS' OOMPENSA'I COVERAGE IS UNLAWFUL, AND SHALL StY6,115616AN;�MPLOYER TO <br /> ATT�t�AL PENALTIES AND CI L FINES UP TO �10,600, tit 'ADDITItlN To ng COST OF ComPE145.0prt, INTEREST, <br /> _ OftHEY°S FEES, A 1 11 o OAhtAGES AS PROVIDED FOR 114sEGTro 37d5C1p THELbtIOR CODE, _. ( <br /> ALIT O IZAT ON FOR OTHER THAN C-57 SIGN INGFER,MIT APPLICATION <br /> fIsignature of C57 tILA <br /> }censed authattzed reptesentativaj, <br /> hereby authorize (print name] SIL— pt to sign thls San Joaquin County Well & boring Permit <br /> Applleallon :on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front.page of thlsapplicallon. <br /> Err:YKi107u&Sh liL.L N:illi ty� <br />