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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> JOB ADDRESS: �I�_..�✓�✓�__S��,K�D� � PERMIT <br /> i <br /> LICENSED CONTRACTORS DECLARATION I <br /> i <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. I <br /> Contractor Name: <br /> License#: CS� VS l6T Expiration Date: <br /> Signature:�_ �� - Title: <br /> Print Name: chers Date: ///r Ile 1 <br /> I <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 /> 0 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 1 <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 /> I <br /> Carrier: J --F .S��c,<�f�3• Policy#:WC,O Date: S <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 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: <br /> t <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 1 <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE 1 <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> I, C Gjol� // ,hereby authorize <br /> Nawof" W anwd iia —_.—_ <br /> yrv�antuitvu {'ilnt tlaino o!R411iatl—1 Agonl ..._.._..-- � <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 dated on the front page of this application. <br /> SlgnMmo of C.67 l AUK. <br /> deJ Raprmvnln vn <br /> EHD 29-018-1-2017 Site Mitigation Well/Boring Permit Application <br /> 1 <br /> I <br />