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Sari Joacluin County Environmental Health Department <br />WELL & E30RING PEFmT APPLICATION SUPPLEMENTAL <br />rrll <br />P 1 <br />JOB ADDRESS: � oya � PERMIT SR #: <br />1-117�,-- <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: \� ,w ��114' 1 �, ' I�6, <br />_:cense #: 6 r7vt J" L vlr-+ \ I.ExDir <br />`signature: A,X�l,� <br />Print Name: Ih/l•1 I t _� --- Date <br />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 />Labor Code. for the performance of the work for which this permit is issued. My workers' <br />co ensationurance c rrier and policy numbers are: <br />Carrier: %�; Policy #: Exp. Date: _ <br />I certify that in the performance of the work fo which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the orkers' co <br />mpensationof California and agree that if I <br />should become subjec to workers' compens ion provisions of Section 3700 of the Labor Code I shall <br />k--� thwith comp wit those provisions <br />Signature: <br />Print Name: _ Va r Li <br />QARNING: FAILURE TO SECURE WORKERS' COMRi=i3'aATION GOVERAGE 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 />UTHI RIZATION_ OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, 1,here y authorize j <br />N C-57 eot Licensee Autfton Re en hw -- -_-� � �'� - •-•- %w •' <br />to sign this San Joaquin County Well &Bong ermit Application on my Behalf. I understand this <br />authorization is valid for one ye r and is I i ed to th Wworplan dated on the tont page of this application. <br />FHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />