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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7-Eleven#17334-4501 N. Pershing Ave., Stockton, CIPERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 /> License#: C( S 3 fn 4(o Exp Date: <br /> Date: /2-L4 I yContractor: ��t`C7 O� �C - p J►1 <br /> Signature: �-' / Title: <br /> Print Name: ( IAA.,(S `1-Q4U (Y-\ <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 /> ✓ 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:-,2 y c i C� An1t- 'tC0—J�Ji'1SU(a poticy Number: W cA 319 33 2 D z, <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> anc agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, Ishall forthwith comply with those provisions. <br /> Exp. Date:-_ 12- 1 1 4// Z-0 I L{ Signature: �� <br /> Print Name: G 1-( 21SA-iZ> ►--( <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Tu M (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Stantec Consulting , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />