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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: C, ��1 •r`'"'`�l'`I 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 ofthe <br /> gCal ifornia Business and Professions Code and my license is in full for a and effect. <br /> License#: c �� Exp Date: <br /> Date: to t o Contractor: <br /> Signature, Title: <br /> - <br /> Print Name: r e-4-- <br /> WORKERS' <br /> yeWORKERS' 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 /> 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 d policy numbers are: <br /> Carrier: <br /> -0.-�-e.�1 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 provisions of Section 3700 of <br /> the Labor C de, 1 �hallforthwith cam ply with those provisions. <br /> Exp. Date: ar Signature: .\ <br /> Print Name: <br /> LOYER TO <br /> WARNING: FAILURE TO SECURE WORKERS*CRIMINAL PENALTIES AND CIVIL FINES COVERAGE <br /> S100,000. IN ADDITIONTO THE COST OF COMPENSATIONFUL,AND SHALL SUBJECT AN , INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO ZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby a Drize(print name)�`VI� �R� , 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 /> WELL PEFUT APP <br /> ENO 29-01 0728710 <br />