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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1 I I `� ��� ���4 PERMIT SR #: <br />V , <br />LICENSED CONTRACTORS DECLARATION <br />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 />I n -. . f <br />Contractor <br />License #. <br />Signature. <br />Print Name <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 />13 provided for by Section 3700 of the Labor Code for the performance of the work for which this <br />permit is issued. <br />I I have and will maintain workers' compensation insurance. as required by Section 3700 of the <br />C� Labor Code for the performance of the work for which this permit is issued. My workers' <br />compensation in nce carrjer and policy numbers are - <br />Carrier: r,_7 Policy #: — Exp. Date: 1 <br />i� � ( � <br />certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br />any manner so as to become subject to�r°r orkers' compensation law of California. and agree that if I <br />should become subject to workers' compensation provisioris of Section 3700 of the Labor Code, I shall <br />forthwitcomply with those p ovisions. <br />�• f <br />Signature. n <br />Print Name' <br />WARNING: FAILURE TO SECURE WORKERS'`66MPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL 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 />AUITHORJ ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby/ authorize <br />N m+ d ,.-67 ,canc+d 4uthonnd R+D+wn,+nw ' im N+m+ of Au ht -d Ag -1 <br />to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for:W�,@ <br />ar andV�! <br />mited to the work plan dated on the front page of this application. <br />1 \rr �i 1;4,-) <br />S-gn+t.. of C_V ItSc�nsed uttW7.k e <br />t\ <br />EHD 29-01 6-23-2015 Site Mitigat,on Well Permit Application <br />