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EHD 29-01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 Business and Professions Code and my license is in full fo ce and effect. <br /> License#: L� t- Exp Date: <br /> Date: 16 Contractor: , <br /> Signature: Title: Y�,������� <br /> Print Name: <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: �1 <br /> Carrier: �_( �� I(� Policy Number: �� �["G�.1A ` � <br /> I certify that in the performance of the work for which this permit is issued, I shall n�.employ any <br /> person in any manner so as to become subject to the workers'(eompensation law of C lifornia, and <br /> agree that if I should become subject to workers' compensation provisions of Section 700 of the <br /> Labor Code, I shall forthwith comply with those provisiogs. <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEtAD'J 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 /> ,AUTHOR�ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> I, <br /> OvAiI, �� �`' (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) \_ ,to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29-01 07120/10 WELL PERMIT APP <br />