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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: GA f Mt�i�-I d- rel l i2-Z� 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 's in fulliforce and effect. <br /> License#: t� v� r Exp Date: J ! Lr <br /> t �� I �, Cil Ill' • ' � � ;�. <br /> Date: ` t Contractor: t <br /> Signature: V\,4\ Title: <br /> Print Name: r, <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 /> —4—1 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 "er and po icy numbers are: <br /> Carrier: / <br /> `��J 1.�--1 L. � r � Policy Number: �1,�;7 L{�_i 14- <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' comp sa 'on law of Cal ornia, <br /> and agree that if I should become subject to workers' compensation pr visio s of Section 700 of <br /> the Laborde, I hall f rthwith comply with those provi ions. <br /> Exp. Date: �� 3 1 Signature: L <br /> Print Name: It I' l rrl'` <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 <br /> SAAS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO TION FCIR OCHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Z' V t (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) CI t , l , 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. 1 i.�,il• t �.�1��' I'I y'j�.t �� C��� � (� <br /> EnD 29-01 03109!12 1 WELL PERMIT APP <br />