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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1620 Eleventh Street,Tracy, CA I 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 is in full force and effect. <br /> License#: G `5 -�- q 5 3 U t,-) �Exp Date: 10 131 -Lo I <br /> t 1I1 C{ <br /> Date: 7-L,,) g <br /> 1-5 Contractor: J et,,{l'l O n_4I E frn� D� � A,�_ , <br /> Signature: < Title: 1 U1V✓ <br /> Print Name: leAA6 , l �l 1-� ,nom <br /> WORKERS' COMPENSATION 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 t0 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 /> 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: } , 2 <br /> Carrier: 1ZU((IC-1A &�l�CAn I fj, i , tJ7.Policy Number: °v 2 l 19 5�zo2, <br /> 1 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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provision <br /> Exp. Date: Signature: �� <br /> Print Name: CI7eAS <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 /> ALITHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> T� <br /> hereby authorize (print name) Stantecto sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this au orization is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> VN 29Li OS 112 WELL PERMIT APP <br />