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San Joaquin County Environmental Health Department <br /> WELL$ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3 PERMIT SR#: <br /> J <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: �� C6 CLSk ( CI �y6•l�lVY1 <br /> License#: Expiration Date: <br /> Signature:, '� V Title: <br /> Print Name: �ti �y e)'V1��11�� Date: <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 /> 13 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: Policy#: 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 workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwit c/omply with those provisions. <br /> Signature: <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 <br /> /I OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ONIYQ�Li �' y{�lll SCI Q � , hereby authorize Cotton, Shires and Associates, Inc. <br /> Nam. L Auth-i-d R".—tAW. Print Nam.of Autnod-d AW nt <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'�limited.to t e work plan dated on the front page of this application. <br /> it—dK-57 ­p—tadv. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />