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0 . <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: <br /> 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 /> Contractor Name: G/eQ� �/i�lir� <br /> � T <br /> License : <br /> Signature: CS 4G l�f" Expiration Date: <br /> Title: <br /> Print Name: <br /> Date: /p lr/Z O �/ 7 <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 /> ❑ provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> �J 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:) 4 �f� Policy#:WG 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 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 /> 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 /> AU R TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i G'r./1ry� hereby authorize <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 Ifm o tf ork pI rCated on the front page of this applicatlon. <br /> SlpwNm O1C6IL Y1 iu�n..q y,y,N, yp ' <br /> EHD 29-01 8-1-2017 <br /> Site Mitigation Well/Boring Permit Application <br />