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San Joaquin County Environmental Health I:I apartment <br /> WELL & BORING PERMIT APPLICATION SI.PPLEMENTAL <br /> -;)LD-A4 r�� N� ��y 98. <br /> JOB ADDRESS: S'f G C.•I,C'1 oro F'I_Rh!IT SR # <br /> LICENSED CONTRACTORS DECLVCATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter c ',commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my lit:orsi: is in full force and effect. <br /> License Exp Date: �2c) i Q� 9 <br /> Date: � �� �S� i f�S Contractor. <br /> Signature: <br /> Title: <br /> Print Name: __. <br /> WORKERS' COMPENSATION DECLAF;A TION <br /> I hereby affirm under penalty of perjury one of the following declaratic-1s: (--heck one) <br /> I have and will maintain a certificate of consent to self-iw;ure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the perfcrr-ance 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 :'ii 3 3ermit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: lt�� � (� Policy Nu ober: �G�—I Z�I )i <br /> I certify that in the performance of the work for w-iich this pi: alit 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 provision:;. <br /> Exp. Date: S+�� � <br /> Ig nature: % <br /> Print Name:_; <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAV'I U_, ikND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, 114 ADDITION '[) '-HE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 : _-H::LABOR CODE. <br /> AUTHO ZAT� �FO OTHER THAN C-5'7 SIGNINI;; PERMIT APPLICATION <br /> u <br /> (signatre of C-5'; lic(!nsed authorized representative), <br /> hob tilorize int name) Tim Cuellar to sign this San .Jo.iq ain County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid f:)r xne year and is limited to the work <br /> plan dated on the front page of this application. <br /> FHn Mnl 070A/10 WELL PERMIT APP <br />