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San Joaquin County Environmental Health Department <br /> WE <br /> ;LL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ka'J�j I Vt 9�U,PERMIT SR# <br /> JOB ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (I.CD) <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#: –C-f 7 —Exp Date: f e4m/&C <br /> Date: -Ir ,grContractor: <br /> Signature: Title: OWW07f6,r Zok,0,0 •.ar <br /> Print Name: <br /> WORKERS' COMPS NSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> ' have and will maintain a certifloate 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 /> —26 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: a Policy Number:&Icwplo W/O/ <br /> I 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' compensation law of California. <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor I shall forthwith comply with those provisions. <br /> Exp.Date: f Signature: <br /> a <br /> Print Name: fry° <br /> F—r C-to <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL suaiEcT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000,IN ADDITION TO THE COST OF COMPENSA-nON, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> U <br /> UT [ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �'r <br /> 'R T <br /> (signature of C-57 licensed authorized' representative), <br /> hereby authorize(print name) to sign this San Joaquin County Well & BoHng 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 /> EHD29-01 p5W12 WELL P.EPMr APP <br />