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San Joaquin County Environmental Health Department <br /> F----WELL <br /> Sc BORING PERMIT RPPLiCAT10R1 SUPPLcfJiEIJTAL <br /> JOB ADDRESS: 7-Eleven#14117,2725 Country Club Blvd., Stockton PERMIT SR# <br /> LICENSED CONTRACTORS DELI-ARATION (LCD) <br /> I hereby affirm that 1 am Pc:ensed under the provisions of Chapter 9 (commem inn with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: r1'S�3(�, Exp Date: <br /> Date: t,U�t �'aR s� c� O I L Contractor: <br /> Title: r"b r I <br /> Signature: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION I <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) 1 <br /> I <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 whish this <br /> permit is issued. I <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier•. S►CinM�f i C rRSV rdCu taQ Number: C 3 <br /> Policy I�3320 3 <br /> I ,ertify that in the performance of the work for which this permit is issued, I shat) not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provis€ <br /> s �0I ,� Signature: <br /> Exp. Date:_� �—��— -------------- <br /> Print Name: <br /> WARNING:FAILURE TO SECURS WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> 1 CRIMINAL PENALTIES AND CI'J;L FINES UP To$10C,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> HORI A i ION FOR OTHER THAN C-57 SIGNING PERMIT APPLI^ATION <br /> IL C _ (signature of C-57 licensed authorized representativel, <br /> hereby authorise(print named Stantec Consulting , to sign this San Joaquin County Well & Boring Pernkit <br /> Application on my behalf. I understand this authorization Is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> VJELI.PERMIT APP <br /> EHD 29 01 05109f12 <br />