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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 /> License#: t -xp Date: 1 <br /> Date: `1 Contractor: _. <br /> Signature: Title. 1. ` <br /> Print Name: 4,i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin(: declarations: (check one) <br /> 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: ,`,CII,i�- ;` �. 1 (� Policy Number: <br /> I certify that in the performance of the work for wr ich this permit is <br /> , <br /> and agree that if I should become subject to workors' 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 <br /> W ING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAC'E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> WX <br /> ' 1�V_4 4.' � Al1tLt-t CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> . ,• .r r , u,,.. r <br /> C9FT-3 ES9�tf &AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (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 2901 01/13111 HELL PERMIT APP <br />