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[ 4 <br /> San Joaquin county En,rironme ital Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD- <br /> 1.hereby affirm that I am licensed udder the provisions of Chapter 9 {coin encing with 5ectlon 70010)of <br /> Wision 3 of the California Business and Professions iwddtl;and my license is In fulltarce a effect. <br /> OzV)}ayyy }prey a e6 I j[j may}jE <br /> License#a EXp DQt�i: i �£ 4 f+ V20 I <br /> Date. ' Contractor:� 11 U <br /> ICU <br /> I CtUn <br /> PrtnfName,: <br /> WORKERS'COMPENSATIC-N DECLARATION <br /> I hereby affirm under pepatty tperjury lrle of the f IdWintl declarations:(check one) <br /> �_.. I; have and will certificate of consent to self-insure for workers' compensation; as <br /> pf(vkied for Oy.00..V130 Of the Labor Code, for the performance of the work ftsr which this <br /> perrnit'3&.rssueif. <br /> have-aril <tiili maintain workers' compensation nsurance: as required by Section 3700 "of the.. <br /> Labor Code, for the performance of the worts tor:which this permit is issued.. My wo(kers' <br /> compensation insurance carrier and.policy nttrnbers ere: j <br /> lCOrrler �. # Policy Number: <br /> l certi.Y.that inthe pertbrmanpe>of the-work for which this.perrnat hs:issued, I shall riot employ any <br /> person in any manner:so as to become subject t:) the workers° compensationlast of California; <br /> and agrea that if`I should become subject to workurs`compensatioin proyisrorts of ectian 37t}D of <br /> t!`ie Labor rCvde,.l'st'r0 f0ithwittt:c:omply with those provisions. <br /> Ezp.Date;I 0 1 2- X-Signature: wv <br /> Rrint Name*_ <br /> WARNING, FAILURE TO sECURE WORKERS'COMPENSATION COV9RAG'E IS UNLAWFUL,AND SHALL 3UB,IBCT'AN!rlVIPLOYEI TO <br /> CRIMINAL i'EN,0.t.nir5.p;lVp CIVIL FtPfFS UP to$100,000,IN ADDITIONTO THE CClST'OF:CCi1VIPENsVinom,:'IN7EAEST. <br /> ATTdRN1ErS.FEE5;;ANO DAMAGES A$PROVIDED FOR IN SECTION 3706 OF THE LABORGOUE: <br /> -i PTHClR1ZATION FOIFWTH•R TFIAN C-57 SIGNING PERMIT APPLICATION <br /> �- — tsignatule of 0-57 licensed euthorizezl.representative); <br /> Hereby au#thorize_(prinCriarne) , to sign this San Joaquin.county Well:.&:.Borlr�g.::Perrriit <br /> Application on:my behalf. t:understand.this authorization is valid for one .6 isIinted.-torstie work <br /> Plan-dated onthe front page oftf is applicatido' <br /> r+azntri:arnerio YBEt KR&DTAPP: <br />