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I <br />{ San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> Country Market <br /> JOB ADDRESS : 10476 W . Linne Road, Tracy CA 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 #: �% `� F !_`I Exp Date: f3 : �t <br /> Date: 2/��5` Contractor: <br /> Signature : "— Title: <br /> Print Name : AL r- <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 /> _ V 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: f fz 4 % L . ,-r Policy Number: flY F e� S— <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 , <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: / f Signature : --- <br /> Print Name : <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 /> AUTH RIZATION FOR OTHER THAN C -57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby a thorize ( print name) k1i cAe i. . . , 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 /> EHE 29-01 OSM112 WELL PERMIT APP <br />