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San Joaquin County Environmental Health Department <br /> WELL& BORiNG IaERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 374 Lincoln Center Stockton, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter A (commencing with Sectior 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> 953646 10/3112014 License#: _' _� Exp Date: ___ <br /> Date: / 1_z -Z,C)I L Contractor: National fE..W.P. <br /> Signature: � () <br /> Title: 1 (D �co; l ��, �Q 1 U, <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> FI 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: <br /> Carrier: � L�1t\rner ca nSvra, e.Q Policy Number: U)(?,g3I9 332-03 <br /> 1 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:._ 0-I IS L`____ signature: -_r�� <br /> J Print Name: � S�a 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$100,003, IN ADDITICN TO THE COST OF COMPENSATION, INTEREST, <br /> AT(ORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (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 /> E11DI -0I 05109.4 WELL PERMITMP <br />