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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: C � 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 C Iifornia,Business and Professions Code and my license is in full force and effect. <br /> 4 <br /> 1 \ <br /> nl <br /> Contractor Name: <br /> \ I <br /> License#: raF'on Date: <br /> � � Exp� <br /> Signature: Title: 1 \r <br /> Print Name: ��� �� ( �� Date: C, L% <br /> WORKERS' COM _RATION 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 /> compens,;ption-insuranc carrier and policy numbers are: <br /> Carrier: Policy#: J` Exp. Date: (� c <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 aw of California, and agree that if I <br /> should become subject to workers' compensa ion provisions of Sect on 3700 of the Labor Code, I shall <br /> i those provisI <br /> IfO hwith comp ws. <br /> Signature:' Aa� <br /> Print Name: ), l v <br /> WARNING: FAILURE TO SECURE WORKERS' CO ENSATION 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 /> UTHORI T FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize C6 L <br /> Name - Licari homed resent ve not ams Azad Agent <br /> to sign this San Joaquin County Boring Permit Appl atiorl on my behalf. t,,pnderstand this <br /> authorization is valid for one year a is Ilited t e work plan ate d o ni the frontpa a of this application. <br /> Slg re o -57 Licensed Authorized R ren 've <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />