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ErjO 29Z 0 q 0 <br /> WELL PEPWIT A.Pp <br /> San Joaquin County Environmental Health Department `C r' Y' <br /> WELL & BORING PERMIT APPLICATfON SUPPLEMENTAL 1 <br /> JOB ADDRESS: Z%A0' 7- m PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I arr licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect: <br /> License #: 1 5� . exp Date: i�' �_�� l-C•1 a <br /> Date: } �� Contractor. 1�,` ' i rr <br /> Signature Title: Sc <br /> Print Name: A; ` F <br /> WORKERS' COMPENSATION DECLARATION ' <br /> t% 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 €;eff-insure for workers' compensation. as <br /> �t provided for by Section 3700 of the Labor Code, for-the performance of the work for which this t <br /> V7* permit is issued- f <br /> 1 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 number are: <br /> ` Carrier: ' F'oficy Number: K1­] '12----1w--:`W- L- <br /> I <br /> - - .1 1 L <br /> �T <br /> 1 certify that in-the performance of the work for whic-i this permit is issued, 1 shall not employ any <br /> ,person in any manner so as to become subject to the workers'"compensation law-of California, and <br /> agree that if I should become subject to workers' Compensation provisions of Section 3700 of the <br /> Labor Code, 1 shall forthwith comply with those pro5Jsions. _ <br /> Exp. Date: Signature: Y <br /> E <br /> Print Name: ", 1 ' <br /> WARNING: FAILURE TO SECUR <br /> CF:INS hI.AL:P.ENALE WORKERS'COMPENSATION COVERAGEdS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> TIES AND CIVIL FINES UP TO$100,000, IN ADI}ITION�TO THE COST OF COMPENSATION,INTEREST, <br /> A.,r7TORNEY S FE S,.ANp DAMAGES AS PROVIDED FOR IN SEC'-ION-3706 OF ETHE.LABOR CODE:' <br /> A''U'TF�ORIZATION FOR THER THAN C-57 SlG-NJNG-PER'MlT APPLICATION <br /> (signature: of C-57 licensed authorized representative), <br /> hereby authorize (pr(name) —D ���it G <br /> to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the workplan dated on t Te front page of this application. <br /> =k029-c'. 07,20110 <br />