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EHD 29-01 0720/10 WELL PERMIT APP <br /> San Joaquin County*Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: &,m)a I CA- 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 Businessland Professions Code and my license is in full f rcce2e ad e ect. <br /> License.#: U Ex Date: <br /> Date: 1 ; ontractor: 1'1 W, <br /> Signature: ►�t1.t,C �� Title: r(Qrel <br /> Print Name: ti�Y I Y C <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 <br /> /an policy numbers are: <br /> carrier: & O`� C-u/ Policy Number: <br /> 1 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 provisionsf S ction 37 f the <br /> Labor C de, I hall forthwith comply with those provisio s. <br /> Exp- D2te. ✓ Siginature: W vmlu <br /> Print Name: Y 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$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 /> _ <br /> AUrWATION FOITHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 Ii ensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin County Well &Boring Permit Application I my be alf. 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 /> EHD 29-01 0720/10 WELL PERMIT APP <br />