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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: LJ LUc. ���-t 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 /> i n <br /> Contractor Name:,--U �' r`J r J __ <br /> License 4 Lf Expiration Date: JL v ' 1-o <br /> Signature: <br /> . - <br /> Signature: - . _�__. __ - ----Title: & <br /> Print Name: 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 /> Labor Code,for the performance of the work for which this permit Is Issued.My workers' <br /> compensation insurance carrier and policy(lumbers are: <br /> Carrier:.-JI-7-_ :�Pwalx , _ Policy#:✓i O Z� /'O/Exp. Date: <br /> �- <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 c ply with those provisions. <br /> Signature: _ �l•-L, <br /> / - - - -- ._..----------- <br /> Print Name: (,6/741 u <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $900,000, 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 (c lJ V j �,✓c'�C� <br /> to sign this Sen Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization Is valid for one year and Is It ted t e work <br /> pla»,dated on the front page of this application. <br /> LHU 29-018-1-2017 Site Mltigetlon Well/Boring Permit Application <br /> Quick Notes Page 2 <br />