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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 and Professions Code and my license is in full force and effect <br /> Contractor Name A"wce _GLn_____Explcro+Qn <br /> License # - �O�q Expiration Date: 5/3 J /2oz-o <br /> Signature - — Title <br /> Print Name. - S 5 -Toi1.ck— 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 /> 13 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 /> 13 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: 1�dv�ol 1��,�n�� � �� Policy #: Exp. Date: Y <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 /> fo yvith mply with those provisions. <br /> Signature: <br /> Print Nam <br /> WARNING: FAILURE TES 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. S 5 T,,JI,,I- , hereby authorize sti <br /> to signrm <br /> this San Joaqu 'Coun <br /> we — _____ — N ui A01-1-1Ag•m <br /> County Well & Boring Permit App ' ation/�n my behalf. I understand this <br /> authorization is valid for one year and is limite t the w pl d don the front page of this application. <br /> 8 5.5,. umo. a •pr•s•nc m• - '--. <br /> t� <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />