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f � <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7-Eleven#17334-4501 N. Pershing Ave., Stockton, C"PERMIT 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#: a—5 J- q5 3 lP Lf(o Exp Date: to�3 I/ Zo I q <br /> Date: T 12-q/1 14 Contractor: oa-4,0,, A- gyp, J JG <br /> Signature: / Title: IAA- a,stir <br /> Print Name: 'FQ.4y M <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 <br /> q carrier and policy numbers are: <br /> Carrier: 2y r i C� Ary\kt-*co-Aj '1SU(arolicy Number: W 4Lq 319 332 02., <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 /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I/shall forthwith comply with those provisions. <br /> Exp. Date: 12-1114/ Z-01 L4 _ Signature: <br /> Print Name: G{-f R S -V-A-`FV M <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 /> 1, h r I S I-A l U 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. 1 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 \NELL PERMIT APP <br />