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;V <br />19 <br />3t� <br />Ice <br />Box <br />Sat <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: �CVCy1Y���-Q C PERMIT SR 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 />a <br />Contractor Name: A,\,oVO� 1� I V \ A <br />01 License #: <br />Signature: <br />ITE Print Name <br />•obe <br />I Tit <br />'ime <br />Co <br />5' <br />5' <br />ubii <br />et <br />te: <br />0 <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 />r 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 pen atio insurance carrier and policy numbers are: <br />Carrier: Policy #: G_ �Exp. Date: <br />I noriif,. ♦h n♦ in 0h nr�rfnrmnnno r.f 4he inrL inr ,uL.inh thin nrmii in ic. c, Berl I nh.11 nna• c+m Ina nn ornnn in <br />10GI LII Y ll lQl 11 LI IV t.IGI IVII1IQI we VI UIG VYVI 1% 101 VVI ll%.dl II 110 FGI I1 Ill IJ 1001AUV, I JI IQII IIVI UI I IPIVy OI IY NGI 0V1 11I <br />any manner so as to become subject to f e workers' compensation law of California, and agree that if I <br />should become subject to worke ' comgensation provisions of Section -3700 of the Labor Code, I shall <br />hwith comply with those proveons. <br />Signature: 4-`++�1� J v 1 <br />Print Name: ( <br />WARNING: FAILURE TO SECURE WORKERS' CO MIPtNSATION 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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APP6I A I IUN <br />hereb uthorizeI 64 Jam. �Y i <br />Name icer epresenlat- T� dnt / e u or and Agent <br />to sign this San Joaquin County e & Boring P rmi Applic�a(tion n my behalf. I understand this <br />authorization is valid for one y and is Ii d to th wo plan dateddn the front page of this application. <br />V,-/-V� A---\_ I n n A <br />EHD 2M1 6-23-2015 Site Mitigation Well Permit Application <br />