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EHD 29-01 0720/10 WEI I PERMIT APP <br /> San Joaq In County'Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �C,l—\ PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the <br /> Businessland Professions Code and my license is in full f rcce2e lla d e ect. <br /> License.#: I U Ex Date: <br /> Date: ontractor: w V. <br /> Signature. �t �� Title: rtL r` <br /> Print Name: ti`Y �Ly- <br /> WORKERS' <br /> COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 /> compensatio insujrraance carrier/an policy numbers are: jun I <br /> Carrier: / a 1 Rt 1 l C� 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' compensatio w of Califo ia, and <br /> agree that if I should become subject to workers' compensation provisions f S ction 3700 f the <br /> Labor C de, I hall forthwith comply with those provisio s. <br /> Exp- Dp-te: Signature: � � 1 IL <br /> Print Name: Y I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES ANJi)QVC FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTQ_RNEY'SFEES No ACeES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AMOATION FORZI�THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, ` ' 4 V, � c i (signature of-C-57 li ensed authorized representative), <br /> hereby authorize(print name) I l u .np <br /> ,to <br /> sign this San Joaquin County Well &Boring Permit Application my be alf. 1-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 /> EHD 29-01 0720110 WELL PERMIT APP <br />