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I <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> I <br /> JOB ADDRESS: CITY OF MANTECA RIGHT OF WAY PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION II <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: 519 1 T / c <br /> License#: C—, Expiration Date: 13 Y 0 <br /> Signature: Title: '?VV 1 Q9L,%— <br /> Print <br /> Name: 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 /> compen(s�ation insurance' carrier and policy numbers are: <br /> Carrier:r �l! �� >z Policy#: Exp. Date: <br /> / <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 su ' t to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forth mply with those provisions. <br /> Signature: <br /> Print Name: L1Lt4`k <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 /> t fc,1/ A �A �?.� <br /> Ha. f� . �p.ti^KC.tZ , hereb authorize G <br /> Neme e,G1 meed uYio,b rPneenlallre 1 mro i <br /> to sign this San Joaquin Cou We)[ & Boring Permit Application on my behalf. 1 understand this <br /> authorization Is valid for one ye an)d t limi d to thgu�rk pl n,,dated on the front page of this application. <br /> / / I <br /> 9'n not C-51 ePmm�l� <br /> 1 <br /> i <br /> I <br /> I <br /> EHD 29-01 8-1-2017 Site Mitigation WaIYBoft Pannit Application <br />