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San Joaquin County Environmental Health Department <br /> W\\``ELLL�L ll& BORING PERMIT <br /> PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: M �`\\ PERMIT 3R# <br /> 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 California <br /> 'lBusiin fess and Professions Code and my license is in full f rc1e and effect. <br /> x1-0`'"�" Exp Date: <br /> License#: "CA0101A, n( <br /> Date: L ' 4`'Signatur <br /> Print Name: <br /> 4<=N <br /> WORKEON DECLARATION <br /> I hereby affinn 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 /> 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 /> compensaTt,�onn in ur cle carr <br /> ier and policy numbers are: <br /> Carrie r:yl SII^ n r. . Policy Number: I✓�� �C�`r / <br /> 1 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' ensation of California, <br /> and agree that if I should become subject to workers' compens Ion rovislons f S ction 3700 of <br /> the LaborCodeli I shall forthwith comply with those pro isron . <br /> Exp. Date: 0 Signature: 111���GGG J <br /> Print Name: <br /> t <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 /> THtZATION O OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l YD) (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) l�k �` to sign this San Joaquin County Well & Boring Permit <br /> Application an 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 /> WELL PERMIT APP <br /> EHD29-01 O 9112 <br />