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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Z06 _r Wer a- Ave CA PERMIT SR#: Leo 7f 13 L <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 <br /> /and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> License Al: j Expiration Date: /� 3/ /rr <br /> Signature Ix. � Title: <br /> Print Name: 1,1_1 /C/ ', 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 /> 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 /> 0 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#/1� 1(�h�O�l7fJ Exp. Date: c> <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 /> forthwith comply ith those provisions. <br /> Signature: - a+e-- <br /> Print Name: <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 /> hereby authorize 55fuar <br /> �Na,no al CT LkmseO A..,1 oJTiepre,m, p„nl Nxrxr of Tutl,urvoJ Agorrr <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 limited to,the work plpn dated on the front page of this application. <br /> / i s <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />