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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 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 /> �eyxwo -e r'• 11 i n -Inc,, <br /> Contractor Name. p ' <br /> License#: 90 8y Expiration Date: <br /> Signature: Title: <br /> Print Name: �va✓1 N�IW� Date: 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> j 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 /> E3 Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> Ico`1mpensationn insuranceg0l8 <br /> .. carrier and policy numbers are: 44 <br /> Carrier: 64co Ireboce, Q. Policy#:i,)WC-�als� Exp. Date: O <br /> W <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ ahy 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 G v n <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000, 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 /> rltl1 ^r1C. <br /> hereby authorize 7e,r�sQhGS.P �oqi lecdInq+1'c• <br /> rtn of - L,canfee u nxd ep,eae ,e . <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year an s limited to the work plan dated on the front page of this application. <br /> i <br /> ,gnawn of L,caoaed Autnomz Rep-­e j <br /> i <br /> t <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />