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M � ' <br /> San Joaquin County Environmental Health fiapartment <br /> WELL & BORING PERMIT APPLICATION SIxPPIXMENTAL <br /> JOB ADDRESS: 235 Scott's Avenue, Stockton CA FEFtii IT SR# <br /> LICENSED CONTRACTORS DECUTARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter g ;commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iworm. is in full force and effect. <br /> License#: TJ� Exp date: j\,�:!(A bio IgSAS <br /> Date: `� 7 .\X�l�l + ��j_ Contractor: <br /> Signature: Title:.A-(—�:,(At;)+ <br /> i <br /> r° <br /> Print Name: .,y __. <br /> WORKERS' COMPENSATION DECLARPTION <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-irisure for workers' compensation, as <br /> provided for by.Section 3700 of the Labor Code, for the pe ftrriance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, a!1 Squired by Section 3700 of the <br /> Labor Code, for the performance of the work for which i> oermit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> a <br /> Carrier: '15AA 2.- BiLd Policy Nu nber: <br /> 1 certify that in the performance of the work for which this p+:rmit 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 provision:; <br /> Exp. Date::-ejCdQR r , 5+ 2A'�ignature: <br /> Print Namre:._"; L acd. — <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAVIFU'-, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, 114 ADDITION "0 -HU COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706'7=''H iP LABOR CODE, <br /> AUTHO /ZAT1 hi FO OTHER THAN G-57 SIGNIN+s F'EiRMIT APPLICATION <br /> 1, (signature of C-51licensed authorized representative), <br /> 116'reby int name) Tim Cuellar 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 /> pian dated on the front page of this application. <br /> EHD2MI Q712NIG WELL PERMR APP <br />