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1 . <br /> San Joaquin County Environmental Health Del artrx ent <br /> WELL 130R['NO PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: St€,r k*:i, California PERMIT 5R <br /> IONS D CONTRACTORS DECLARATION (LCD) <br /> w <br /> hereby afCimi that I ani`licvrtsed Ocld r the prr~Visions Cif Chzipter 9 (cornmeneing with Section 7000 of <br /> Division 3 of the Califbrnica Business and Professions Code.arid rny:iicanse is in full.force end effect. <br /> License r. r�,7 7�, L. Exfa Date,, It <br /> Date: _ Cgritractor: .;:L_;. _ <br /> Print Narne' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby ae i€rYl a,irad�ar,pen itty�of perjriry ne of the follcP.,vincd doclFrations: (check oale) <br /> I have Pnd 'will maintain e ;c6rtificate of consent.to sell-insure for wc)rkers' Compensation, as � <br /> -- —otovided for by Secb(5n `37 Of the Labor CDde, for the pea'formance of the ,vo.fk for which.tliis <br /> permit t5 issued, l <br /> i 'have and will .maintain wotkers' corn,pensatiorl insurance, as required by 5ectfUn 370+3 of the <br /> or Code, nor the per oFMance of thu work wI is 1 <br /> t this permit is issued. My vjorkers" <br /> r rnpertsation insurance carrief and policy nril`r slx> rs ane; <br /> ICarrier; � <br /> 11W—Fns, (o-Policy Number,. Z7-W-6VL\4 <br /> I celtily that Ira the perforrri4Ae of the work for which this permit is issued, I shall -Trot employ any <br /> persori in any mariner so -.3S1. tc t�CC0n1C- strt�ject to the workers' compensation Iaw ns Calilcrnia, <br /> .aad agre?that it I should beocir� su ect to workers' cornpensalian provisions of Section 6tuo of <br /> the Labor Code, I shall forth',ith comply y,ith those°provisions_ <br /> Exp. Date: l`t ( J f Signature: <br /> Print ttill�t i i <br /> WARNING.FAILURE TO SECURE VJORKERS'COMPFNSATIOr4 COVET AIIE IS UNLAWFUL,AND:SHALL_SUBJECT AN EMiPLOY€R TO <br /> CRIMINAL PENALTIES AND DIVIL.!FI ES LIP TO S101)AQ7, IN ADDITION TO THE COST OF COMPENSATION. INTEREST. <br /> ATTQPNEY'S FEE'S,AND DAMAGES AS PROVIDED FOR IN SECTION 3i06QF THE LABOR CODE, <br /> AUT RI A ON FORT' ..TH R `KHAN Ca SIGNING PERMIT APPLICATION <br /> I. (signature of C=67 licensed authorized repr�eseritative), <br /> hereby authorize (print name] uc i to sign this San Jongi,iin Couni€y Well & Boring Permit <br /> Appiic.ation on my behaif. I iinderstand this authod-zatibn is valid for orae year and is tirnitCd to the work <br /> plan dated na the front page of this application. <br />