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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMEhrTAL <br /> JOB ADDRESS: PERMIT SR V <br /> LICENSED CONTRACTORS DECLARATIOII'I (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (Gommenci Tg 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#: 9 3 6 7(o Exp Date: 2-2 2 % I 2 0 ( Z <br /> Date: S 2 d Contractor: 2ur K� I lot o 1--In C . <br /> Signature: �/ I 4U.E_,�- Title: 'tor aq a�+ <br /> C <br /> Print Name: V IV -I A Z3 <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 werkels' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance cf the work for which this <br /> /permit is issued. <br /> t 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 issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier. I V z V 5 i'i SvV � Policy Number. _LJ— U ;5 <br /> 1 certify that in the performance of the work for which this permit is issw d, 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: ayr Z ) 2 o [! Signature: <br /> Print Name: j/t H S '( a K-c ti <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAY_L 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 /> A AUT UKILA 1 IQ N I Ut{1 ft THAN G-OT 310HIN0 PCRMIT ArPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> A <br /> hereby authorize(printname)6Ino -ro-K Ack Ato 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 /> EHD2401 WaWIG WELL PERMIT APP <br />