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11 <br /> San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : I V17S'av*Vtn OFazho .Arhlyt S>* Jk.+hh g*0A RSiol, 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 California Business and Professions Code and my license is in full force and effect. <br /> License #: C Lyy (p / Exp Date: __ Z/ <br /> i— <br /> Date : 7 ?r Ill Contractor: Fr, * .:T1w, 6S 5 <br /> Signature: � � Title: Ch, e c < 431 .� <br /> Print Name;/ _JQ Nie c At Jacobs <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 insurancecarrier and policy numbers are: <br /> andCarrier: &!Q Policy Number: c12 - LOa X100 <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 Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 1 � I ` } Signature : ;' <br /> Print Nam • ays s A . c & <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,0009 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I , i (signature of C-57 licensed authorized representative), <br /> hereby authorize (print In to sign this San Joaquin County Well & Boring Permit <br /> Application on mybeh t . derstand this authorization is valid for one year and is limited to the work <br /> plan dated on the nt page of th, application. <br /> EHD 2901 07/ &10 WELL PERMIT APP <br />