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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:- W. Washington St PERMIT WP #: <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 />Contrac <br />License <br />Signatu <br />Print NE <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 />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 />5q Labor Code, for the performance of the work for which this permit is issued. My workers' <br />ens tion kurance carver and policy numbers are. j <br />Carrier: % Policy #: I Cj��'/ 7 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 s ct to the workefs' compensation law of California, and agree that if I <br />should become subject to ers, compensation provisions ` of Section 3700 of the Labor Code, I shall <br />fo hwith comply wit those provisions. <br />t <br />Signatur k, <br />Print 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 />UTHORIZATION FOR OT <br />0 1 <br />', 14YA, �1 <br />to sign this San Joaquin Cou?tq Well & <br />authorization is valid for ongye d *4imi <br />THAN J=57 SIGNING PERMIT APPLICATION <br />here y authorize <br />Print • o} AU MOrl2W —Am. V <br />'ing Per it Application on my ehalf. I understand this <br />4o the wo k plo dated on the front page of this application. <br />EHD 29-01 8-1-2017 \1-- __1/ Site Mitigation Well/Boring Permit Application <br />