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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 /> 248 Industrial, Stockton, CA <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 force and effect. <br /> ' y �c <br /> License#: Ex <br /> � ��-'"�` p Date: /3- c/ <br /> c�� i�lube Dry <br /> Date: C' �, v)'2- Contractor. L. � w <br /> Signature: Title: <br /> Print Name: ' VJ <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---- <br /> I ave 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:SfPk— 1UtiC/ C,),41Z J-,`) Policy Number: ���'U 3 6, —e`�� ( I <br /> I 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, and <br /> agree that if I should become subject to workers' compensation provis" ns of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions <br /> Exp. Date: �U d �1�/ 2- Signature: <br /> Print Name: 4�9titij S G l- <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 /> AU RIZ ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature of C-/57 licensed authorized/re resentative), <br /> hereby authorize(print name) a ,c%� C- ,to <br /> /�L <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 07/20/10 WELL PERMIT APP <br />