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San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPL CATION SUPPLEMENTAL. <br /> JOB ADDRESS: to,3o S. 04tV67 AV6;,1tluE J rftr-rvw PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o- Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cod 3 and my license is in full force and effect. <br /> � cC <br /> License#: ;� 1 Exp Date: ,,( <br /> Date: t.. .0 — Contractor:.[ `A . 'li [-N.J i W] le 1\1 h <br /> Signatur�w - ' <br /> Tile=, <br /> C <br /> Print Name)1(1AV <br /> WORKERS' COM PENSATIC N 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 consen 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 /> X I have and will maintain workers' compensation nsurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work 1 Dr which this permit is issued. My workers' <br /> compensation insurance carrier and policy number 5 are: <br /> Card er.-S1(AA � yld -__-- I'olicy Number: -11 2�701- :0 ) 0 Cl <br /> 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 t) the workers' compensation law of California, <br /> and agree that if I should become subject to workE rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 1nature:g <br /> Si _ - <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAG: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 SE(TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATIONFOR OTHER_THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signatul a of C-57 licensed authorized representative), <br /> hereby authorize(print name)Gant 1y-1.fAC_-1 y , to sign :his San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization s valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> _J <br /> DID<9 01 07r2W10 VVE.,I�E_RMII APP <br />