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EHD 29-01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 712 Main Street, LOCM, CA PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCU) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: 953646 Exp Date: 10/31/2014 <br /> Date: 10-30-2013 Contractor: National EWP. Inc. <br /> Signature: _ _ _ _ itle: Manager__ <br /> Print Name: hris Tatum <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: Zurich American Insurance Policy Number: WC931933202 <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Lal:or Code, ! shall fortli ith comply v.;ith those p!cv,sions. <br /> Exro. Date: 12/12/20].3 S;gnature: <br /> Print Name: CHRIS TATUM <br /> I <br /> `.NARWNG:FAIL URE TO SECURE WORKERS'COMPENSATION COVERAGE!S UNLAVffUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> GkiMINHL FcNALT1ti AND(,11ifL FINES UP iU$iOJ,UGO,IN AUi)IiIUN iU'iHE COST OF GGiNPENSAi!ON,INTEREST, <br /> ATYORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN G-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) ERIK APPEL / TERRA PACIFIC GROUP ,to <br /> sign this San Joaquin County Well & Boring Permit Apnlication on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> L <br /> EHD 29-01 07'20110 WELL PERMIT APP <br />