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r <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7675 W. 13 th St., Tracy 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#: / ;�'�`� ( ° 5� Exp Date: <br /> Date: �j�Z. Contractor: z4t�r`"G:= <br /> Signature: 1 ,,,ti v. �� . r_�-� Title: <br /> J' G: <br /> Print Name: <br /> t <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 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 /> X 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 carrier and policy numbers are: <br /> Carrier: -/-I Policy Number: OI o% : C, <br /> I 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 1 should become subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply With those provisio S. <br /> Exp. Date: { �f�f Signature: <br /> Print Name: `.��, ,1r ^ ice• <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$900,000, 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 0C (signature'of C-57 licensed authorized representative), <br /> hereby authd/i a(print name)(94k 6;..50X6-K1 to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. l understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 2801 05109112 WELL PERMfT APP <br />