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San Joaquin County Environmental Health 04' <br /> wirtment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 31808 WeS�` t^-" t 5—h `3ER?AIT SR# <br /> LICENSED CONTRACTORS DECLI'�RATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter f: (c,ornmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my lice 7,;a is in full force and effect. <br /> F <br /> License#: 3R23M Exp Date: __.� —01 LP <br /> Date: 1 Contractor: �: ..���° t <br /> Signature: �• Title-. '� �?-1 W <br /> Print NaNle: `J Qin <br /> WORKERS' COMPENSATION DECUtit-vaON <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-insur--! for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the p;.rfxmance of the work for which this <br /> permit is issued. <br /> „l have and will maintain workers' compensation insurance, cs required by Section 3700 of the <br /> Labor Code, for the performance of the work for which tHs permit is issued. My workers' <br /> compensation insurance carrier and policy numbE,rs are: <br /> Carney:,��- „� Policy Wim! :r: <br /> I certify that in the performance of the work for which this p¢krinil is issued, I shall not employ any <br /> person in any manner so as to become subject to the world m' compensation law of California, <br /> and agree that if I should become subject to workers' comps:n5ation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thosa provisiomv, <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERF,GE IS UNLA fW01-,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALnES 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 37416 OF TI-JE LABOR CODE. <br /> AUT <br /> ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-M' licensed authorized representative), <br /> h e authorize(print name)-ura&I %11Jkyk'Q*, to sign this San Joaquin County Well & Boring Permit <br /> Application on 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 /> EHE 28-01 WOWS S WILL PERMIT APP <br />