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AWL <br />San Joaquin County Environmental Health C?epartment <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />• : r . t / om/moi e: <br />s <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 />e 5 <br />License:# - 3340 Exp. Date: ®/�1,2—e 3 <br />Date: ��o'� 1/ Contractor <br />Signature: <br />Print Name: ,ate_. y <br />WORKERS' COMPENSATION. DECLARATION <br />I hereby affirm under penalty of perjury one of the foilawing 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 perfonnance of the work for which this permit is issued. My workers-° <br />compensation insurance carrier and policy numbers are: <br />Pljfo� llcy Nurnb er:V% 61 -0 <br />7 <br />I certify that: in the perforrrlance of the work for which this permit is issued, 1 shall not employ any <br />person in any manner soas 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 3,700 of <br />the Labor Code, I shall forthwith. comply with those provisions. <br />txp. Date:^_ Signature: <br />Print Name: 91, <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL. SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CM FINES UP TO $700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE.LABOR CODE. <br />AUTHORIZATION FOR OTHER. THAN 0-57 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 />plan dated on the front page of this application. <br />&P 29-01 .07128110 WELL PERkWT APP <br />