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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> [Division <br /> RESS: 235 Scott's Avenue, Stockton CA FIEFtB'IT SR # <br /> LICENSED CONTRACTORS DECLFIRATION (LCD) <br /> affirm that I am licensed under the provisions of Chapter C ;c�rnmencing with Section 7000) of <br /> of theCalifoornia Business and Professions Code and my li erste is in full force and effect. <br /> : Exp Date: .' `Lr 1 �lQ <br /> Date: ti �X1 Y�T__r_� - contractor: li. �--- <br /> Signature: Title: . k ,l <br /> Print Name: ---- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following deciarati(mE: I;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 pe rfcrn-lance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, at; required by Section 3700 of the <br /> Labor Code, for the performance of the work for which rni; aermit is issued. My workers' <br /> compensationinsurancecarrier and policy numbers are: <br /> Carrier: 1N --e- A Policy Nwnber: <br /> certify that in the performance of the work for which this pt:,mit 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, f / <br /> � � 1�- " <br /> Exp.Date: ignature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAVfF'U uND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION "O "HE: COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706(1-"H'.LABOR CODE, <br /> AUTHO ZA FO OTHER THAN C-57 SIGNIN13 PERMIT APPLICATION <br /> (Signature of C-5' I Cansed authorized representative), <br /> reby orize ' nt name) Tim CUeliar to sign this San .fo,lg lin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid fur one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> END 24-01 07MMI0 <br />