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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ' 'I�Wit PERMIT SR #: <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 <br /> aliforniBusiness and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> License #: CAD Expiration Dat : <br /> I Cd A LN <br /> Signature: Title: v <br /> 3 Print Name: y � r� 1 � Date: , <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 /> 1 1 I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> CDC\ Labor Code. for the performance of the work for which this permit is issued. My workers' <br /> comens'a Ion insdrence carver and policy numbers are: J <br /> Carrier: JL 1 GC Polic Y #: — Ex . Date: <br /> P <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�Ok workers' compensation law of California, and agree that if I <br /> should become subject to workers' corgpensation provisiorLs of Section 3700 of the Labor Code, I shall <br /> forthwit comply with those p ovisions. <br /> Signature: <br /> Print Name: L <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 /> AU HOIII ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> Narm d G lxeneetl Au4fwnieC epneenYnve / Ow:. of Autnpn»o Ag—, <br /> to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one y \r and is invited to the work plan dated on the front page of this application. <br /> w(.1 \ <br /> 3lgn tum of C47 ut1w7iZab kepm n <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />