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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: � 11�U� 11 �(�-'L PERMIT SR #: <br /> Cil' <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 /> Contractor Name: <br /> License #: ( 1 Expiration Date. <br /> Signature: __Title: �K5 <br /> Print Name: if, � r� ' ,1 Date: <br /> Sf <br /> WORKERS' MPENSATION 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 /> 13 provided for by Section 3700 of the Labor Code. for the performance of the work for which this <br /> permit is issued. <br /> �x) I 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 in nce carrier and policy numbers are: <br /> Carrier: J 1�1� ! L't�} Policy , Exp. Date: <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�4 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 /> forthwit comply with those p ovisions. <br /> Signature:'` - ''L I ,fl-/C,N 16/ <br /> Print Name <br /> WARNING: FAILURE TO SECURE WORKERS' MPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, 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 /> A <br /> hereby authorize <br /> Pnm N.me of Ammo-"agem <br /> to sign this San Joaquin Count Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one y ar and is imited to the work plan dated on the front page of this application. <br /> S,gn.t n w Gs. .ns.0 mho .prose. n <br /> i � <br /> 1 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />