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1 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 /> _ <br /> License#: +. I =xp Date: <br /> I <br /> Date: _ ` -� \ �; Contractor: _ 1, '�� ( �'► Il \> V ;�V 1 l( 1 <br /> Signature: Title: ', <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc: 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: ���C\1�. ��-1, 1` O Policy <br /> <br /> , <br /> and agree that if I should become subject to workl:!rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name:_ <br /> W I FAILURE TO SEC URE.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 /> W40 <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SE1,TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatu-e of C-57 licensed authorized representative), <br /> hereby authorize (print name) 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 /> EH0 29-01 01113111 AELL PERMIT APP <br />