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San Joaquin County Environmeital Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l am licensed under the provisions of Chapter (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in fullforce and effect. <br /> License#: CJS 1 `Exp Date: 10/ F) ) ( 2-01 <br /> J <br /> . <br /> Date: ~ -,n ( )aC n .� r�l ) Contractor:)1 WC I <br /> Signatur.e:_- ��:..'.. '::� dile.� ICU- l'. I- <br /> i Print Name: # t.���1 ( 1� J�a r1-j�- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinll 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, I have and will maintain workers' compensation 'nsurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work iDr which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: 7 <br /> Carrier: 3�C. A-v1� )Y-\.Oj Policy Number: t� )-rIl :I(`)u)—)C) <br /> I certify that in the performance of the work for wl-ich'this permit is issued, I shall not employ any <br /> person in any manner so as to become subject tJ the workers' compensation law of California. <br /> and agree that if I should become subject to work( rs'compensation provisions of Section 3700 of <br /> the Labor Code. I shall forthwith comply with those provisions. <br /> Exp. Date: j 2 D S - Z - Signature: " <br /> Print Name:_ kt��: <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 SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> =--�- ' -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 /> EHD 29U: 07R&ID <br /> Y ell MgM!iAP <br />