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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FJOBDRESS: 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#: ( '� � dCs�C` Exp Date: --/ 3f �Z��1 <br /> 5 C��Ci b i iK..)(.�1.�1' rz1 A�1 <br /> Date: Contractor: f y <br /> —� <br /> Signature: U, "LtTZUft`STitle: PreS/d f/`t <br /> t <br /> Print Name: Cone c_Y7 G L <br /> WORKERS' COMPENSATION DECLARATION 7 <br /> 1 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 Cade, for the performance of 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: yS 1 i H <br /> •1 (V L1 Lr-d Policy Number. kt,,I�r7-D <br /> c <br /> I certify that in the performance offthe 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 Califomia, <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: { 2o1y Signature: /�J�'( lLc� [t ' �73�C tCYGtC <br /> f Print Name: lhri - Gti117P �cJ �� <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 n <br /> LaZ y� i (signature of C-57 licensed authorized representative), <br /> hereby authorize print name) H, kC f f4-01! JL) , 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 /> END 2901 05!09112 W ELL PE VAI'AP' <br />