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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 455 E 11th St. Tracy, CA, 95376 PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectio 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force anV effect. <br /> I <br /> Contractor Name: gene cc O(tl11,101nG' <br /> License#: qM19 ExpirationDate: <br /> Signature: _.,,, Title: C�0 <br /> Print Name: 7yw-� Date: 8 <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'compensa ion, 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 3 00 of the <br /> 0 Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> 'co`\mpe\nsation insurance carrier and policy numbers are: <br /> W <br /> Carrier: 'fCC7 �eb1yXC CO, Policy#:WWC-3a18q-4G Exp. Date: 8 aol8 <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 comply with those provisions. <br /> Signature: <br /> Print Name: I A U n <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 7015100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, Ah D DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZrATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATI N <br /> r� I lf1�I 1�4 VIC hereby authorize 7C(f SIG f 1 n 1� <br /> to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understa nd this <br /> authorization is valid for one year a s limited to the work plan dated on the front page of this application. <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Pe it Application <br />