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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:Kerry Blvd./Muela Ranch Rd., Mountain House, CA PERMIT WP #: <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: <br /> License #: t{ Expiration Date: <br /> Signature: Title: <br /> Print Name: AmaivL 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 /> 0 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 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:,544-k �� , �S �Policy#:9G$QNo` -CRO,-20 Exp. Date: 'a034 <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 toer ' compensation provisions of Section 3700 of the Labor Code, I shall <br /> fo hwith co ly with those provisions. <br /> Signature:_ <br /> Print Name: h <br /> WARNING: FAILU4 TO SECURE ORKERS' 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 /> I, 4WNAAa_� • W , hereby authorize Mauricio Luna <br /> Nam. C-57 Llceneod Authorized Representrve Print Name of Authorized Agent <br /> to sign his San Joaquin Clunty Well & B4e 'ng ermit Application on my behalf. I understand this <br /> authorization is valid for one year and is limite rk plan da on the front page of this application. <br /> SlgnaWre of C-57 Licens Autho ative <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />