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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT WP #: <br /> �SZ�S <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 <br /> ' roProfessions Code and my license is in full force and effect. <br /> Contractor Name: �,1�'1L/ l ' �/r <br /> License#: _.___ _Expiration ate: Z(�Z /� <br /> Signature: / _Title: �S ._ 41A Ila <br /> Print Name: ---ATYLa _ L _ ��` Date:--— j' ?,V,2_02-0 <br /> WORKERS' CO SATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dE.clarations: (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, ft,r 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 /> O 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 /> o n � I�y�U p <br /> Carrier:�R.�l_fJ n1Z:�W1Yl (Policy#: �'� ���Ex Date: Q- /2,/Z UZ� <br /> 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 l <br /> should become subject to work s' ensation provisions of Section 3700 of the Labor Code, I shall <br /> it co I with those provisions. <br /> Signature: <br /> Print Name: 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 /> 1ZDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> A)�'PROVIDED FOR IN SECTION 3706 OF THE LAEfOR CODE <br /> AUT'H I TIbB FOR OTHER THAN C-57 'IGNING PERMIT AP <br /> PLICATION <br /> I hereby authorize'Namiofb3 llCanfd R.prese� � .--to sign this San Joa Coun W oring Permit Application o .I understand tis <br /> authorization is valid for on r and is im to the work blan dated on the front page of this application. <br /> —' pnalunopnsS n14W.— <br /> EHD 29-01 8-1-2017 Site Mitigation well/Baring Permit Application <br />