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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: PERMIT WP #: I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect, Contractor License #: Signature: Print Nam4 I hereby affirm under penalty of perjury one of the following declarations.- (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as 0 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I I have and will maintain workers' compensation insurance, as required by Section 3700 of the ?d Labor Code, for the performance of the work for which this permit is issued. My workers' r\ pe sa insuran e carrier and policy numbers are: Carrier: Policy #. Exp. date: I certify that iri the performance of the work for which this permit is issued, I shall not employ any person in i any manner so as to become subject to the workers!, ompensation law of California, and agree that if I should become subject to work in ensatio "pr isions of Section 3700 of the Labor Code, I shall Z 1, rQ ith 7wi those provisions, =111M 110 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A14 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHO-...R.. IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION hereb uth0 ri'ze to sign this San Joaquin Countdll & Boring Pe It Application o my behalf. I understand this authorization Is valid for one year,niql4alinllto to the ork plan dated oto the front page of this application, EHD 29 18-1-2011, Site Mitigation Well/Sonng Pamt Apphcatjt,,.,