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')., ap YI:II.PCkN?II AF'P San Joaquin County Environmental Health Department WELL& BORING PERMIT APPLICATION SUPPLEMENTAL i JOB ADDRESS: t ,I ,i r; 1,1 L ;L ' s;;,:, PERMIT SR# LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I ani licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of tho Business and Professions Code and my license is in full force and effect. License# L L_._. . _ Exp Date: t Date V.._w�` i �.- Contractor: Signature: Title' Print Name..... -_'�== £ (A i WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of peolury one of the following declarations: (check one) I have and will rnaintairl a certificate of consent to self-insure for workers'compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' j compensation Insurance carrier and policy numbers are: j Carrier.: )o ,'_; Policy Number: i1,il\\ tom; l f! ' � f I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation law of California, and I agree that if I should becorne subject to workers'compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Exp. Date:_1;7 t Signature: S :s.L v ul I, L r.� i.kJ-N, Print Name: i VVARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, A'TTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION (signature of C-57 licensed authorized representative), hereby authorize(print name) _ ,to sign this San Joaquin County Wel 8 Boring Permit Application on my behalf. I understand this authorization I is valid for one year and is limited to the work plan dated on the front page of this application.