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San Joaquin County Environmental Health Department <br /> WELL & BORIN IT APPLI;-ATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR # <br /> i <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 Cod( and my license is in full force and effect. <br /> License#: =xp Date: ��� �i Jl L_l t� <br /> Date: IC►) L} \ Contractor ', �� -��� (���7CU�'aC,ry1 k ► <br /> Signature: ��� Title _ � ), l a0 6 <br /> Print Name: <br /> WORKERS' COMPENSATIC N DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin( declarations (check one) <br /> i <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't� ��; 1 Policy Number: <br /> I certify that in the performance of the work for wl-ich 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 work(!rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 1_ Signature: <br /> Print Name:- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA< E 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 SE:TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 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 /> EHD 29-01 0 V 13111 h'ELL PERMIT APP <br />