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San Joaquin County Environmental Health Department <br /> WELL sic BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _500 W. Hospital Road, French camp, CA 95231 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#: 4 9 9 0 8 Exp Date: 10/31/14 <br /> Date: 4/28/14 Contractor: Krazan & Associates, Inc . <br /> Signature: Title: SPni or Manaccrp <br /> Print Name: Michael Bowery <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 workers' compensation, as <br /> provided for by Section 3700 Of the Labor Code, for the performance of the work for which this <br /> permit Is Issued. <br /> 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: Heffernan Insurance Brokers PollcyNumber: 90837012014 <br /> 1 certify that in the performance of 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 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 p vi io <br /> Exp. Date: 1/1/1S Signature: <br /> Print Name: Michael Bowery <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 /> I. (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , 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 worts: <br /> plan dated on the front page of this application. <br /> EHD 2"l OSM12 <br /> WELL PERAYT APP <br />