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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />� ' <br />JOB ADDRESS: Q-`�- PERMIT SR #: <br />LICENSED CONTRACTORS 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 Business and Professions Code and my license is in full force and effect. <br />Contractor Name: <br />License #: <br />Signature. <br />Print Name: <br />WORKERS' GOMPENSATION 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 />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 have and will maintain workers' compensation insurance.. as required by Section 3700 of the <br />L� Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation in nc:�a7er and policy numbers are: <br />'t <br />Carrier: nL Policy #: jl <br />Exp. Date: 1 <br />I 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,the workers' compensation law of California. and agree that if I <br />should become subject to workers' compensation provisio s of Section 3700 of the Labor Code... I shall <br />forthwit comply with th " e p ovisions. <br />Signature: _Y/�fl e 1 <br />1 <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS"G-OMPENSATION 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 />ERMIT APPLICATION <br />hereby authorize <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one y ar and is imited to the work plan dated on the front page of this application. <br />3lgnature of C-57 17 <br />11, hateb Represen ti <br />.t <br />EHD 29-01 6-23-2015 Site Mitigation Wel! Permit Application <br />