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San Joaquin County Environmental Health Department <br /> WELL $ uORiNG PERMIT APPLICATION SUPPLEMENTAL <br /> Jos ADDRESS: 6455 Pacific Ave Stockton, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herehy 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#: 953646 Exp Date: 10/31/2014 <br /> Date: _ Z_� ZO t contractor: NatlOnalE.W.P. <br /> Signature: /} � Title: <br /> Print Name: l ', � ri, aATU ,?`-t <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 Cede, for the performance of the work for which this <br /> permit is issued <br /> LJ_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(iGy, Qrller Oce 7J �SurM� Policy Number: U)&R3 tLI 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' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:.___h4I S/_z c_7 I u ___ Signature: fr ��� <br /> Print Name: l VI �-s—f itAV(YL <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 /> ATfORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. i <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 /> pian dated on the front page of this application. <br /> FHD2MI C9A;12 <br /> WEL, PERHITAPP <br />