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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT WP#: <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. 4 !"\��1 C <br /> License#: p�q / Expiration Date: 9_ <br /> -- — ------- c <br /> Signature: _ Title: JU. <br /> Print Name: y��G Date. 10 — 1 — -" <br /> RKERS' CO PENSATION 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 /> O 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 /> compensation insurance carrier and policy numbers are: 'n / a► <br /> Carrier: Q1rQ. �Y►3ut c, ��1 Policy#:-9ObJ� -20 Exp.Date: � L � / <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 ubject to the workers'compensation law of Califomia,and agree that if I <br /> should become subject to work s'compensation provisions of Section 3700 of the Labor Code, I shall <br /> f ith comply with thos provisions. <br /> Signature: <br /> Print Name r)C <br /> WARNING: FAILURE TO SECURE WOR ERS' PENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER T CRIMINA 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 /> 1P4friCK C. (7l/IC9Rr"ti` ra.y yvppw <br /> I, . Vh0(.� hereby authorize aV4* t.y"� <br /> ,,,. a ,.me,-�xw ", <br /> to s n this San Joaquin ounty Well Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is lirnl d to I dated on the front page of this application. <br /> ErHD 29.01 6-1-2017 Site Mitigation weimoring Permit Application <br />