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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: t O / ht PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br /> <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 r3r-e‘O ///‘) <br />License #: Expiration Date: <br />Signature: <br />Print Name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />0 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />I have and will maintain a certificate of consent to self-insure for workers compensation, as <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 />compensation insurance carrier and policy numbers are: <br />Policy #: Exp. Date: S/1/ Carrier: J L <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 to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />. forthwith comply with those provisions. <br />Title: Ag. <br />Date: <br />1/3/ IS) <br />Signature: <br />Print Name: <br /> <br />04--€ d <br /> <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 />( ( r)( e _ , hereby authorize / <br />N.uno ul 9•51 Aulhorited-Roprosontativn Print Natilbdt /Whom.' A pill <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and fs limited to the work plan dated on the front page of this application. <br />/oLlmits.fitelmn.nuili- <br />Site Mitigation Well/Boring Permit Application EHD 29-01 8-1-2017