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San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 19 CPERMIT SR# <br /> VC��f_I <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 CaliforniaBusinessand Professions Code and my license <br /> II in full For�'cee/ and effect. <br /> License#: V Exp DDate: N 1 W <br /> Date: J ontractor: c't� ` V I <br /> Signature: �/ Title: <br /> Print Name: ,`v t V� <br /> WORKERS'COMPE ATION 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 /> AI 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 /> compensat' insurancetciiInner <br /> �and policy numbers are: <br /> Carrier. CC r R n <br /> 11L t L V Policy Number: x �� <br /> 1 certify that in the performance of the work for which this permit is Is Lied, I hall not employ aDy <br /> person in any manner so as to become subject to the workers' com ensati n law of Cali mi <br /> and agree that if I should become subject to workers'compensatio visio sof Section 700 f <br /> the Labor Pode, I shall forthwi comply with those rov' ions I �I <br /> Exp. Date: Q..U. Signature: ` I'm <br /> ' t h al <br /> Print Name: n� <br /> WARNING:FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEC EMPLOYER TO <br /> CRIMINAL PENALTIES AND L FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTO EY'S FEES,ANDD MAG SAS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1 A RI,ZATION.FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (si? ature of C-57 licensed authorized representative), <br /> hereby authorize(prink name) t� 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 /> EHD2MI �12 MLLPERMITAPP <br />