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San Joaquin County EnvironmeTtal Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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,: and my license is in full force and effect. <br /> License* J 1 Exp Date: 1 -t) ) { 1_L } 2 <br /> Date: SC _i 7 t`.CC 4 1 �7�1 I Contractor: )I I h�1 1fN <br /> 1I Yc I 1 J Cil )1)J�-' <br /> Signature: <br /> PrintName: <br /> WORKERS' COMPENSATIC N DECLARATION <br /> t hereby affirm under penalty of perjury one of the followin(I 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 /> I have and will maintain workers' compensation nsurance, 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 s are <br /> Carrier_5Ack-VL '"t 1 `Y-\Gj Policy Number: <br /> I certify that in the performance of the work for wf ich this permit is issued, I shall not employ any <br /> person in any manner so as to become subject ti the workers' compensation law of California. <br /> and agree that if I should become subject to works rs' compensation provisions of Section 3700 of <br /> the Labor Code. I shall forthwith comply with those provisions. <br /> Exp. Date: ! Ci C \ Signature: < - <br /> Print Name:- 1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAC E 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 4, —fsignature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , 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 front page of this application. <br /> DID29401 07n&10 <br /> nfU uERlde qPF+ <br />