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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I�o22 howc..4 Z--c .- S bac Khan. CA PERMIT SR <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: .�JcoAu a{ A � � ���� <br /> License* QJS-7--71 on-? (-) Expiralb Date: +7- 3 t- t"1 <br /> Signature: Title: (q�f <br /> Print Name: <br /> Date: <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 /> 0 provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I�ave 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. tMum Policy 4:� Jb �� t Z p 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 agree that if I <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> l forthwith comply with those provisions. <br /> Signature: / "06 OAAk2 <br /> Print Name: t (�Jocauayjy-CL <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 /> h iereby authorize _ uy, _ WS¢h <br /> Ali- <br /> to sign th. ,_n 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 /> EHD 29-01 &23-2015 Site 4 igabon WeU Permit Application <br />