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0 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORiNG IaERM1T APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 374 Lincoln Center Stockton, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the prr visions of Chapter q (commencing with Sector, 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Li:ense#: 953646 exp Date: 10/3112014 <br /> Date: I Z_L z o I L contractor: National E.W.P. <br /> J <br /> Signature: //_} �� ��--t� Title: r� k�L� ��e.�'�Q i V i �C)2, <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally 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 Cede, 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: p <br /> Carrier:�u -K—C"—Wr Ca-,� sSC2 ,le Policy Number: 33 20 3 _ - <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' cornpensatiun provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:._ 0- <br /> 15 J Z U I L Signature: <br /> — -/----� ---- ---P --------- <br /> Print Name: Le C�sTa--u ry% <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 ADDITICN TO THE COST OF COMPENSATION, INTEREST, <br /> ATrORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3108 OF THE LABOR CODE. i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1• —___--___-________—____ (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 work <br /> plan dated on the front page of this application. <br /> EIID 29-0I OLOB;1? -- <br /> WEL. PERMIT APP <br />