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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 /> 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: crzN C�}[_lFo�rv,,� , (►ti L <br /> License #: x-06 5-6 S Expiration Date: S�31/ <br /> Signature: Title: (U <br /> Print Name: M fz I S(ZP1&4 Date: I <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 /> 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 /> 1� 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: Policy#: Z i✓f C LY71 �-j Exp. Date: to 1� <br /> I-certify-that-ie4M <br /> should bw_cQPAe swbject to r <br /> Signature: <br /> Print Name: M1A2k--- -A `Z Cz e�-5A <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 /> I, j'"11-N2K__ , hereby authorize TnNY &J 4 Ltiy l <br /> Name of C57 Lkensed Authortud Rep,.—I.tive Print Name of Authorized Agent <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 limi!# to the rk plan dated on the front page of this application. <br /> ign ensed Authorl d Represenletive <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />