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• 0 <br /> San Joaquin County Environmental Health Department <br /> WELL Sr BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 30 91 A1cY W 1W &0 AWY ViXPERMIT 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 the California Business and Professions Code and my license is in full force and effect. <br /> License#: C-S7 (045970 Exp Date 9Ze1G <br /> Date: Contractor:ENV. LiJTROL A�lOC i�i1/G �Ec.4) <br /> Signature: _ 7, -7 ar Title: /APaZE;10— <br /> Print Name: TI Ft -rxLx)� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the-Labor Cade, for the performance of the work for which this <br /> permit is issued. <br /> V 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: STATE FOX"t) Policy Number: _ 1'7-2 ZO7 6 — 201¢ <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: 5'131201S Signature: L <br /> Print Name: 'f U1 '7yEEYZ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, 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 /> I (r( (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ART MO(1PILL , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> Enc 2301 0sro1115 <br /> WELL PERMIT PPP <br />