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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL He BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 16888 McKinley Avenue Lathrop CA 95330 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 and Professions Code and my license is in full force and effect. <br /> Contractor Name: Krazan &Associates Inc. <br /> License#: 499908 Expiration Date: 10/31/2018 <br /> Signature: Title: Senior Manager <br /> Print Name: Michael Bowery Date: May 25 2017 <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 <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 /> Travelers Property Casulty <br /> Carrier: company of America Policy#: PTi7R4F83999417 Exp. Date: 01/01/2018 <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 /> f hwith corn y with th provisions. <br /> Signature: <br /> Print Name: Michael Bowes <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 /> Nam olC6 imns Au omWRepresmuhve Pnnt Neme of uMonz Apm, <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 plan dated on the front page of this application. <br /> signamm a censatl AUMovetl Nepresmtl,lve <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />