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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 /> I � I D <br /> 1 <br /> Contractor Name: <br /> License #: Expirati n Date: �- <br /> Signature: U Title: is t.l;k/ <br /> Print Name: VA Date: <br /> WORKERS' C ENSATION 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 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 /> mpensati suranc�carrier and policy numbers are: <br /> Carrier: Policy #: C I 1 r Exp. Date: I <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' co pensation law of California, and agree that if I <br /> should become subject to workers' compensation provisi ns of Section 3700 of the Labor Code, I shall <br /> rthwith comply with th e provisions. <br /> Signature: <br /> Print Name.- <br /> WARNING: <br /> ame:WARNING: FAILURE TO SECURE WORKERS' PENSATION 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 /> A1UTHORIg6TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> `` II <br /> 1, , ts, l l V I'l hereby authorize <br /> Name of C57 Licensetl tnorizetl RepresentativePri Name of Au oozed Agent <br /> to sign this San Joaquin C u y Well Bonng'Permit Application on y behalf. I understa his <br /> authorization is valid for one yea an I"m ed to t e work plan dated on he front page of this application. <br /> r <br /> Jq <br /> Sig a ura of C-BT icensetl A i tl MoresMaiPe <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />