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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOS ADDRESS: Vtt), � 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 theQ-1ifornia Business and Professions Code and my license is in full force and effect, <br /> Contractor Name: \ I <br /> License#: Expiration Dat <br /> Signature: Title: <br /> Print Name: Date <br /> WQRKER�,' C�MPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foilowing 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 /> Von insuran e carrier and policy numbers are: <br /> Carrier: W)an Policy#:.1_01.1 �W(Dl7f 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 theompensation law of California, and agree that if I <br /> worker '-c: <br /> should become subject to work.QW-eOmpensation pr isions of Section 3700 of the Labor Code, I shall <br /> 16rthwith comply wi those provisions. <br /> i <br /> V <br /> Signature; <br /> Print Name, I \J <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 /> ly <br /> hereby authorize <br /> to sign tols 4 San Joaquin Countykt�ill &, oring Permit Application oy my behalf. I understand this <br /> authorbudJonlis valid for one year And Is 11 to the work plan dated oh the front page of this application. <br /> A <br /> k <br /> V4\,t <br /> I 81004hn of C47 <br /> 77 <br /> END 29-018-1-201 site fAtigation Well/Bonnq Permit Applicatfoo <br />