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San,Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS- <br /> 404d, 7f Y 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 forte and effect. <br /> License#: ->C c <br /> 40c ,c Exp Date: S/31 ab <br /> Date: /) <br /> b -o,o Contract.or:--TTG �Jor��M COJ& <br /> f —A Ou <br /> Signature: XAA Title: Stc-oz-6-L.i <br /> Print'Namer— KZvw!� I& <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.37G0 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 is-sued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:- S-I%o,4 V-1 Policy Number: <br /> I certify that in the perf6fmanice 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 <br /> . provisions of Section 3700 of <br /> the Labor Code, I Shall forthwith comply with those provisions. <br /> Exp-Date:- 4 Signature: -JAI IR <br /> Print Name*. <br /> T-- <br /> WARNING. FAILURETO 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (Signature of. G"57 licensed authorize <br /> herebylutherize(print name) to sign this San i ..d representative), <br /> .9 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 an the front page of this application. <br /> END29-01 07r2MD <br /> VVELIPEF(FAITAPP <br />