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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ot:ern Road) 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 /> Contractor Name: California Push Technoloaies, Inc. <br /> License* 884827 Expiration Date: <br /> Signature: Title: t tatiL r <br /> Print Name: Date: -2 6 / j <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 /> E3 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: Sh„L.Ct:.,r:.;„¢, FIAc1 Policy#: `J l q7 cl ( G Exp. Date:_I0-l7- 20 / 2z <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 /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: <br /> T <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. hereby authorize <br /> .—HN.a,a3,unn..e un nme u.w.. <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 to the work plan dated on the front page of this application. <br /> END 29-016-23-2015 Site Mitigation Well Permit Application <br />