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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: it-70-7 & Ave , 6ZnLKM2rJ t4- 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#: q,l nco g t/J Exp Date:Irl,/ al 6:1Date: LZ�I5I7g1L4 Contractor: &I"fDAaI BVI' , IA(, - <br /> Signature: Z— Title: <br /> Print Name: C–H IZ� ( ATU Y`(\ <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 /> LI 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: eZUridA AtA&4EACAv') Policy Number. �Ga3��13?7ZC� <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:--4 0 117 0 1< Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, 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 /> 11AUTHORIZATI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (/y 1(Lh � (n-I)J l/V,, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) . 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 /> Way KRWT"P <br /> EH020.01 OYDi'fT <br />