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EHD 29-01 07/20110 0 0 WELL PERMIT APP <br />JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />PERMIT SR # <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 full force and effect. <br />License #: c t 7 � �� Exp Date: /37/ <br />Date: �L Contractor: ��G� ✓id , ��i� <br />Signature: Title: <br />Print Name:�/? ,y <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, for the performance of the work for which this <br />permit is issued. <br />1 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: Policy Number: )WO770291/ <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, 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 provisio <br />Exp. Date: / % / 1 - Signature: <br />Print Name: �,1�h'r/ ��u,�K%/ <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 SECTION 3706 OF THE LABOR CODE. <br />AU O ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature of C-571icensed authorized representative), <br />hereby authorize (print name) <br />,to <br />sign this San Joaquin County Well & 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 the front page of this application. <br />EHD 29-01 07@0!10 WELL PERMIT APP <br />