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Sart-Joaquin County Environme tal Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LGD) <br /> I hereby affirm that t am licensed under the provisions of Chapter'g (commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Cod--:and,my license is in full force and effect. <br /> License.#: _ Exp Clare. t <br /> Date. - �_Contractorj)l un I br C1n ( n-v <br /> Signaturr— <br /> We <br /> Pont Name. , <br /> WORKERS' COMPENSATIC;N DECLARATION. <br /> I hereby.afIrm under penalty of pegUtybne afthe following declarations:(check one�l <br /> —thave and wilt maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3704 of the Labor Grade, for the performance'of`the work for which this <br /> permit is issued. <br /> I have and.will maintain workers' compensation�nsurance, as requiredby Section, 3700 of the <br /> Labor Code, for the performance of the work lir which this permit iIS issued.. My workers' <br /> compensation insurance carrier and policy numbet s are: <br /> Carrier: KJG`�.-1'�,,� F'cllicy Nurr,ber: � �'• ��(�� "`'��: <br /> 1 certify that in the perforrrtar>ce of the work for wt•ich this permit is issued, I shattriot employ any <br /> person in any manner so as to become subject 0 the workers' compensation taw of California; <br /> and agree that if I should become subject to orkr=rs'compensation provisions fif Section 3700 of <br /> the Labor Code.I shalt forthwith comply with those provisions. _ <br /> Exp 'balms. I . ` <br /> Signature: :. <br /> Print Flamer_ <br /> WARNING»;FAILURE TO SECURE WORKERS'COMPENSATION COVERAG E 13 UNLAWFUL,AND SHALLsPORJECT.AN EMPLOYER TO <br /> admiNAL PENALTIES AND ciAL EINES UFS TO 5100.000.IN ADDITION TO THE COST Of 4;,MPEIrJSpT[OAt.[Nr£RES:T., <br /> ATTOgN#Y S.FEAS ANTI.DAMAGES AS PROVIDED FOR IN SECTION 3706 BJP THE LABOR Ct)I}E, <br /> AUTHORIZATION FOR_OTH�R THAN �-57 SIGNING PERMIT APPLICATION: <br /> of C-57 licensed authorized representative), <br /> hereby Authorke(print name) , to sign this Sart;Joaquin County,, 1I.A.goring Permit <br /> Applicatldoi'on my behalf: l understand this authdrization Is valid for one year and istlrntted to:the wank <br /> Calan dated:urt the front page.of`this application: - <br /> 93-oz4f C??/16{10 WSLEPERNTAPP <br />