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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7-Eleven #20632-4627 Da Vinci Drive, Stockton, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 infullforce and effect. <br /> G <br /> License#: �� JCO L' (� Exp Date: O I A <br /> � 1 L` <br /> Date: Contractor: <br /> Signature: / Title: Pdto t t cT F.Rv i s c-.3 2, <br /> Print Name: <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 /> 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 n (KSPolicy <br /> mbers are: t '1 <br /> Carrier: "u\)Q -rA NMS r\CGi r1 Number: W �3 i C�33 --O I— <br /> [ certify that in the performance of the work for which this permit is issued, I shall 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 provisions. <br /> Exp. Date: 2 ( � 2Q - Signature: / <br /> Print Name: NI-L1 &� 14-\-uvv-,, <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> [,AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> `y _ (signature of C-57 iicensed authorized representative), <br /> hereby authorize (print name) Stantec Consulting , to sign this San Joaquin County Well & Boring Permit <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 /> EHD 29-01 05/09/12 <br /> WELL PERMIT APP <br />