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EHD 29-01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 821 South Wilson way, Stockton, CA 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 Business and Professions Code and my license is in fullforceand effect. <br /> License#: y�_)J`I Exp Date: <br /> Date: Cl QT Contractor: <br /> _ Yt s C�Pilt <br /> Signature: Title: <br /> Print Name: { \ <br /> WORKERS' COMPENSATION 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, to- 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: ��,At Ta Policy Number: <br /> I certify that in the performance of the work for whim 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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. ' <br /> Exp. Date:�Q py11`--t r �S' t'�17�'� Signature: <br /> Print Name:_ 4k4yi _b(1C11� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES 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 SEC'ION 3706 OF THE LABOR CODE. <br /> AUTHORIZATIOff FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> Daniel Villanueva <br /> hereby authorize (print name) , to <br /> sign this San Joaquin County Well 8 Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on tie front page of this application. <br /> Esq 29-01 0)26tC <br /> I'LL—PS RMI'prp <br />