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i <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 401 N . S n 6e St S � PERMIT SR# D�l3L$ <br /> JOB ADDRESS: d TO t C t�7�) �� o� / <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#: p Exp Date: <br /> Date: 16 h Contractor: clk <br /> Signature: '2 .�/ Title: <br /> Print Name: <br /> WORKERS' COMPENSATION 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 consent 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 insurance, as required by Section 3700 of the <br /> I 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: u)Yl T Policy Number: <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 1 should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. G� <br /> Exp. Date: � � �� .Signature: � • <br /> r <br /> Print Name: L4 <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 /> AUTHORI ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby author' (print name) �'� sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this au orization is valid for one year`and is limited to the workq <br /> plan dated on IIte front page of thig.application.• { �t <br /> R.. <br /> Fl-ID 29-01,f17l18110 •': •�. • WELL PSfMITAPR <br /> 9 { <br />