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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: PERMIT WP M <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 <br />License #: <br />Signature: <br />Print Name <br />Expiration Date - <br />Title: <br />— <br />ate -Title:- <br />Date:_ j 0 <br />WORKERS' COMPENSA`riON DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check acne) <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 />compensation Insurance carrier and policy numbers are: <br />Carrier:.%— Q.� Policy #: _!a.?L' LL3,q v Exp. Date: <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 provisions of Section 3700 of the Labor Code, I shall <br />Inn ihwitl l comply with those provisions. <br />Signature: 1'/` <br />)T- <br />Print <br />Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 />R THAN C-57 SIG <br />I, _l�JGL,= b�- , hereby authorize �✓OrE �D-+iT`I� _ <br />Nan�oi��il n a�,hm onr�Wnlal w PAW A o�Aul�orliM nt <br />to sign tris San Joaquin Count ell $ Boi ing Permit Application on my behalf. I understand this <br />authorization k, valid for one year and Is limit(�d to the work plan dated on the front page of this application, <br />EHD 29.01 8-1-2017 Site Mitigation Wall/Boring Permit Application <br />