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San Joaquin County Environmental Healtl Dei:artment <br /> WELL & BORING PERMIT APPLICATION A1F PLEMENTAL <br /> JOB ADDRESS: 42, 101, 104, & 110 WEST BEVERLY PLACE, TRACY CA Ah D PERMIT SR#: <br /> CTIY OF TRACY RIGHT-OF-WAY ON WEST BEVERLY PLA(:: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (c:)rrrreneing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my''oE nse is in full force and effect. <br /> Contractor Name: � 'tY <br /> License>e: <br /> L1a S� _Expiratr m Datw.ii �� D <br /> Signatur +Title:� y, ( Q-y <br /> Print Na <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 to*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 me uired by Section 3700 of the <br /> ® Labor Code,for the performance of the work for which this petrni:is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: -k ', Policy#: 91-Q31\- .'i` ._ 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 lvw of California, and agree that if I <br /> should become subject to workers' compensation provisions of Sectir)n 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: � ---- <br /> Print Nam _— <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, i",r'ORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C57 SIGNING 1: ERMIT APPLICATION <br /> S�Q hereby authorize_ <br /> to sign this San Joaquin County Well &Boring Permit Application an my behalf. I understand this <br /> authorization is valid for one year and is limited to the woorr dated c the front page of this application. <br /> ---•— <br /> EHD 2Ml 6-23-2015 sito Mitigation Well Permit Application <br />