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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 (cornmencing 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 u A, <br /> License# Upq Expiration Date: 9 <br /> Signature: Title: JCL. <br /> Print Name: NSADate /e — 3 1 1 <br /> RKERS' CO PETION 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 /> C3 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 /> 191, Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: e► <br /> Carrier: f0wo. Tmf, 1r44` Policy#: �06 �DJ� 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 California,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: ne <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 /> I, \ < 0hereb authorize CA a1 . <br /> to s' n this San Joaqu�­Y* <br /> ounty Well Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year and is limi d to I dated on the front page of this application. <br /> EHD 29-01 8-1-2017 Site Mitigation WeII/Boring Permit Application <br />