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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _ __ _s1? J .._ {-t�. .__....._. 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 /> Contractor Name: J(Otq 61 er\ <br /> License#: ��. Expiration Date; 1 2 <br /> Signature: - - Title: <br /> Print e: Date: L4 U U tD -- <br /> WORKERS' COMPENSATION DECLARATION <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 /> 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: .`' J-LA�3 g FA hr-�,qA -- Policy#; Cj�.jl"44 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 <br /> should become subject to workers`compensation provisions of Section 37- <br /> forlhwith com with those provisions. <br /> Signature;, <br /> Print Name: c `�_I 71 qsq- <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORi _..•�.,ve5 <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING' iPERMIIT APPLICATION <br /> hereby authorize AM 6�g� t b tli mrt� t <br /> .„ <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization Is valid for one year and is limited JoAhA wip*-pl I ited on the front page of this application. <br /> EHD 2"1 8.1.2017 Site Mitigation weNlBoring Permit Application <br />