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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 previsions of Chapter A (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 /> License#: 953646 Exp Date: 10/3112014 <br /> Date: __ j / -2 2-1-2-C)I t_ Contractor: National E.W.P. <br /> Signature: / c� Title: r"D cel -cC.i'?Q t V i S Ea[� <br /> Print Name: l ', ri -TA-F " <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 spit-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 fol which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: u 1t �1(�rtter ca � TSvra,�e. Pollcy Number: W 66319 33;203 <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:._ 0-1I5I L1 <br /> r ____ Signature: PP� � <br /> Print Name: l Vt t S�CL 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 ADDITION 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 /> I• --____—__--__-__________ (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 /> pian dated on the front page of this application. <br /> EH02941 O�I99tl2 ----- <br /> ML. PERMIT"P <br />