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FiHD 29-01 OWMII0 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORINGPERMIT APPLICATION SUPPLEMENTAL <br /> �l ' <br /> JOB ADDRESS: �p�- 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 Business and Professions Code and my license is in full f rice/�a d Tct. <br /> License <br /> #: V Exp Date: J <br /> Date: ? t ontractor: 1�1' I ' Kc <br /> Signature: Title: yni(tL <br /> Print Name: �JY <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 an <br /> policy numbers are: <br /> Carrier: �l 1 Cts / l G� 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 =ion <br /> Califo ia, and <br /> agree that if I should become subject to workers' compensation provisions f S coon 37 f the <br /> Labor C de, I[hall forthwith comply with those provisio s. <br /> Exp_ Date: Signature: <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 /> AU O ATION FOIL THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, � (signature -57 li ensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin County Well 8 Boring Permit Application 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 />