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.10 <br /> Ai1011 �11_t� 1�)� ', , <br /> 0 /i�0 <br /> u, <br /> San Joaquin County Environmental Health 6partment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: r6 y 7 � -Glib/G Ay, Tt�G�ns,r l 64 PERMIT SRO (l l <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby 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 farce and effect. <br /> License#: DL 5 y s ExpL. <br /> Date: S�3t 1 . <br /> Date: I1 ho /2=o�i Contractor: <br /> Signature: _tL-- 1 Title: actiavu <br /> k�e�.��i [�. <br /> Print Name: <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 Code, for the performance of the work for which this <br /> permit is issued. <br /> _Y 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:- <br /> re:Carrier• C' -�' 1 Policy Number: Z <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 /> Earp. Date: Signature: Li 13(1 <br /> k IZl <br /> Print Name; �c•�,.� _ (A���t� ._.�� <br /> WARM G-. 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 ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereb authorize (print name) T� , 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 Moret page of this application. <br /> M 2801 07rM10 WAL PERh1R A" <br />