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0 <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />I hereby affirm that 1 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 # 3 I Exp Date: 0161/"1,3 <br />Date:%%j Contractor: <br />Signature: _—�'J' Title: `✓� <br />Print Name: <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 Secfion 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />VI 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 />YGVaNid <br />Carrier: 1Q56r �• dF '(�{��rW'41'icy Number: &C <br />f 716 <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: �VI I Signature: --�~ <br />Print Name: 0. Ag��— <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 />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) . 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 />pian dated on the front page of this application. <br />EiD 29.01 07128110 <br />WELL PERWAPP <br />