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JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />PERMIT SR #: <br />CTORS DECLARATION <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 B inessand Professions Code and my license is in full force and effect. <br />Contractor Name: V\% .Ni <br />License #: <br />Signature: <br />Print Name: JA 1 <br />Title: <br />Date: <br />Lim <br />WORKERSNCOMPENSATION 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 />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 />c eIn urance c,�rrier and policy numbers are: <br />Carrier: %' Policy #: -i � �Exp. Date: i I <br />I certify that in the performance of L work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation law of California, and agree that if I <br />should becomVsubDje t to worker co pensation provisions -of\Section 3700 of the Labor Code, I shall <br />fd�thwi ccommply with those provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COM ENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIM1W PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />UTHORIZ TION FOR /OTHER THAN C-57 SIGNING PERMIT APPLIQATION <br />I, G , hereby author afl l( '0� <br />Name L Ze <br />setl d rosen <br />epmw M me — <br />to sign this San Joaquin Co ty ell & Bo ing Permit Application on my behalf. nderstand this <br />authorization is valid for on � y limiiled o the work plfm gated on the front pa � of this application. <br />EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />