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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS . 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 #: 6q � 74 , Exp Date : /2.3/ /2 1,K <br /> Date : Contractor: <br /> Signature : // Title : aGrJJ'c� !— <br /> Print Name : /� GYYPti.� ZZ 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 /> 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 : <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 I should become subject to workers ' compensation ovisio of ction 3700 of <br /> the Labor Code , I shall forthwith comply with those provisions . <br /> Exp . Date : Signature : <br /> Print Name : f�7�iC��r�✓ ,mac �N � k�? <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 /> RIZ TI N FOR OTHER THAN C -57 SIGNING PERMIT APPLICATION <br /> I , (signature of C- 57 licensed authorized representative) , <br /> hereby authorize ( print name) AJ 6 ' i , 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 . <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />