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San Joaquin CountynviE ronmental Heaitt 00PIrtment <br /> Fhere <br /> ELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> C... Pf:F;MIT SR# <br /> S1E+c.�tOr`/��►�n <br /> CENSED CONTRACTORS DECLARATION (LCD) <br /> at I am licensed under the provisions of Chapter eI Ic(:mmencing with Section 7000) of <br /> alifornia Business and Professions Code and my li ,,na;e is in full force and effect.(J. Exp Date: 1 1 t� J,Ljj <br /> S* � Muni- <br /> Date: i ni-- <br /> Date: Contractor � t { .:�-— - - -- � <br /> Signature: Title: <br /> r " <br /> Print Name:_ � � <br /> WORKERS' COMPENSATION DECU'RVION <br /> I hereby affirm under penalty of perjury one of the following declara ions (check one) <br /> have and will maintain a certificate of consent to self-'nsura for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the I:L:r`o'mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insuranoo 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: � <br /> \U 4 1 � Policy N,Irrb,t:r: <br /> I certify that in the performance of the work for which this :�:rmit is issued, I shall not employ any <br /> person in any manner so as to become subject to the wcik,�rs' compensation law of California, <br /> and agree that iI should become subject to workers' coml:rersstion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisiolts. <br /> f <br /> Exp. Rate: I nature: <br /> Print <br /> LL SUBJECT AN <br /> YER TO <br /> WARNING:FALURE TO <br /> PENALTIES AND CIVIL FINES UPA OO$100,000,IGE IS UNLJ+ <br /> IN ADDITION FC14E COST L, AND AOF COMPE SATIONP O <br /> INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37011 firTHE LABOR CODE. <br /> AUTH OR OTHER THAN C-57 SIGNIt, 3 PERMIT APPLICATION <br /> (signature of C-!;7 li,:ensed authorized representative), <br /> I, <br /> ereby uihork p nt name)�+� Cy£i}A/ , to sign this Sall Joaquin County Well & Boring Permit <br /> his authorization is valid to:' one year and is limited to the work <br /> Application on my behalf. i understand t <br /> plan dated on the front page of this application. <br /> WELL PENNdT APP <br /> Ery02p..01 0712WO <br />