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i <br /> FP <br /> San Joaquin County.Environmental Health Department <br /> WELL.&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7675 W. 11 th St., Tracy PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 �e't..� Exp Date:, <br /> Date: /. - Contractor: <br /> Signature: Title: ` <br /> Print Name: ! "� �•'Z.- <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: Policy Number: x <br /> 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 provislops. <br /> Exp. Date: .P Signature: sr <br /> 1 4 ! <br /> ftf. .Print Name: <br /> I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES.AND CIVIL.FINES UP TO$300,000,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 /> r AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> f" <br /> 1, til />, __. . (signature of-C-57 licensed authorized representative), <br /> hereby autho a(print name)C:'0,P 5�to 'sign this San Joaquin County Well & Boring Permit <br /> Application 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 this application. <br /> EHD 29-01 05109/12 WELL PERM APP <br />