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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADDRESS: Mn((QV 91Wd MaGiLA PERMITWP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Secti( n 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force a id effect. <br /> Contractor Name: 1> <br /> License#: 06 B Expiration Date: <br /> Signature: Title: Geo <br /> Print Name: Date: 9 I t <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 3 700 of the <br /> 0 Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: \,L�tsCp 1,6S. CZM0 Policy #: 32.1'5-[110 Exp. Date: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ a iy person in <br /> any manner so as to become subject to the workers' compensation law of California, and ag ee that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor C de, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, �ND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, ANP 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 AJ <br /> "this <br /> EPUNMW 0.apnem4liva Pnm Name of PUNo ze Ppmt <br /> sign this an Joaquin County Well & Boring Permit Application on my behalf. I understat d this <br /> authorization is valid for one year an 1 ' ed to the work plan dated on the front page of this application. <br /> I <br /> p aNno� ulM1oelee apnaan,alrva <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Perrhit Application <br />