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EHD 29-01 07/20110 <br /> WELL PERMIT APP <br /> San Joaquin County Environme,ttal Health Department <br /> WELL H1 BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 I cense is in full force and effect. <br /> License#: Exp Date: NW Yh 12�' <br /> Date: 7tb, 2-2-i,Cl, Contractor . wo N_X'i V-00i�o 1(I l C <br /> Signature: Title: 1^IftS\6ej_)t <br /> Print Name: �)_nLa'Y� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc, 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, fcr 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 and policy numbers are: <br /> Carrier: Aakf t"l a YA Policy Number: L <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 1-ie workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. f <br /> Exp. Date: 1 L 1 �; Signature: _ <br /> Print Name: (2l tx-y-;l- 0 S' fa 1I t_ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAG::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�TH�ORIZAT _ $ O ER THAN C-57 SIGNING PERMIT APPLICATION <br /> --"%- ���' (signatu-e of C-57 licensed authorized representative), <br /> hereby authorizeprint name) , to <br /> sign this San Joaquin County Well & Boring Permit Applicat on on my behalf. 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 /> EHDnot 01rza10 <br /> WELL PERMIT APP <br />