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SeloSe <br /> San Joaquin County Environmental Health partment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL. <br /> JOB ADDRESS: 707 (�,¢ PERMIT SR # <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 theCaliforniaBusiness and Professions Code and my license is in full force and effect. <br /> License#: V 6 5 6 g Exp Date: 5�3t /),o G <br /> Date- I z/30 /2o�i Contractor: 1 FG- !8V� SAL E,.,,,,,, <br /> Signature: -1 Title; ac fia>r� <br /> Print Name:_ �eti�� k� <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 /> C <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 � �Ci�„�; 11 .'.y-� Policy Number: 3Z (A)EC.CL.` T) ; <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 Califomia, <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: Signature: 6�, <br /> • Print Name: ,,,so v+ <br /> WARNING: FAiLURE TO SECURE WORKERS'COMP ENSATtON COVERAGE 15 UNLAWPL1L AN0-#FfALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PL-NAA-TIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO.THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S`PEES,ANO DAMAGES AS PROVIDED FOR iN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, `-- (signature of C-67 licensed authorized representative), <br /> hereb authohze(print name) _ } ��. , to sign this San Joaquin County Well & Boring Permit <br /> Application ork my.behalf. 1 undery anti this authorization is,valid for one yeas aryl.is limited.to Me work <br /> plan dated on tA"nt page of this application. . <br /> -` <br /> EHD 2%01 070VIO 1 <br /> • WELL MAW APP <br />