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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: C N i Z >C: <br /> ) - _ <br /> License#: /v% 22- Y y Expiration Date: 0 3 �(5z <br /> Signature: --�' <br /> Title: 0 w N � <br /> Print Name: �,Vwrs 6,t(- <br /> - Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 13 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 /> Q 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: rn C�eN w�L?L-A h Policy#: D e, �;�'Z 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 wo kers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: J��t�A— ,� ►2 0� = T� <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> Name of C37 Licensed Aulhonzd RpnsmtatryPrinl Name o!Authonnd Agent <br /> to sign this San Joaquin County Well & Bo'ng i Irmit Application on my behalf. I understand this <br /> authorization is valid for one year and is limit <br /> it to e work plan dated on the front page of this application. <br /> Sig re o 7 Licensed Authorized Representative <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />