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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> j <br /> 1 <br /> JOB ADDRESS: 3yG PERMIT WP#: <br /> 1 <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 /> f�� I <br /> Contractor Name: G/,0. ,- <br /> j <br /> License#: CX- f Expiration Date: //a,/ <br /> Title: ( <br /> Signature: <br /> , �- 3R��^ O�ls dri �iCr ' <br /> Print Name: Cw e.,- Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) ! <br /> + <br /> i <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> d provided for by Section 3700 of the Labor Code, for the performance of the work for which this j <br /> permit is issued. <br /> 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 insurance carrier and policy numbers are: <br /> Carrier: 3 -7 `� ��i��`l Policy#:{NC O z` .3'sel-WExp. Date: b. <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in i <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 /> i <br /> Signature: �.��,_ I <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 /> hereby authorize _ <br /> N.+nw�f7—U o+1ud Au WorltoA(IPylaaentollvu Punt Nmno of lanl+urdoq Agrni <br /> to sign this San Joaquin County Well& Boring Permit Application on my behalf. I understand this <br /> authorization Is valid for one year and is limited to the work pla ated on the front page of this application. <br /> - — i <br /> 61nnn1nln of C.67 06.,Aod o110f—1{1n,+f...of.11 o <br /> i <br /> EHD 29-01 8-1-2017 Site Mitigation Weil/Boring Permit Application I <br /> I <br /> I <br />