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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5950 E.Woodbridge Rd. Acarro CA <br /> PERMIT SR# <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#: 7 0904 <br /> I <br /> E Date:`April 30,2015 <br /> Date: Contr ctor. <br /> Signature: I �[ <br /> Title: JJ <br /> Print Name: v, ) <br /> WORKERS' COMPENSATI 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 /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensa n ins rance rnerr�anndd policy numbers are: 'l <br /> Carrier: f �/l/ Policy Number: <br /> I certify that in the performance of the work for which this permit is ' I shall not employ any <br /> person in any manner so as to become subject to the workers' ompens ion law of California, <br /> and agree that f I should become subject to workers' compensate proves; ns of Sec ' n 700 of <br /> the Labor C de, I shall forthwith comply with those rov' iion/5. <br /> Exp. Date: �� Signature: 74 <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPL ER TO <br /> CRIMINAL PENALTIES D CIVIL FINES UP TO $700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> AT42 <br /> TORNEY'S F ES,AND AMAGES AS OVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> U O I ION FO DTHE THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> (signature of C-57 licensed authorized representative), <br /> hereby authoriz (print name <br /> to sign this San Joaquin County Well & Boring Permit <br /> Application on m ehalf. I u derstand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EH029-Di M09/12 <br /> WELL PERMIT APP <br />