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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: Ii. , L i k•A 9 52(32-PERMIT SR OS: <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 />s. Contractor Name: 1) t <br />License #: 1 oclai4 Expirat. n Date: ,L it3 24.)14!) <br /> <br />Signature: 1 (WI i'(._ Title: <br />Print Name: I Date: 1() Oh/ <br />WORKERS' COM2ENSATION 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 />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />0 Labor Code, for the performance of the work for which this permit is issued. My workers' <br />cotintiensati'on i surance carrier and policy number are: <br /> <br />Carrier: rt \c Policy 0: Exp. Date: 2./f r7 ..,7f lk, I/ <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 subject to workers' compensation provisions of-Section 3700 of the Labor Code, I shall <br />. t forthwith comply with those pro_yisfons. , <br />4,1( . r <br />WARNING: FAILURE TO SECURE WORKERS' COMPE14SATION 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 />MI 0/ -3T I Ike nme.,..• -1 ont•dA wit <br />to sign this San Joaquin County Well #, Bolring Permit ApplIca,tion on my boha f. !understand this gt <br />authorization Is valid for one year an 191fillted to the wcirk Ian da Ge on the front page of this application. <br />Signature: <br />Print Name: <br />AU7ORIZATI7 FOR OTHER THAN C-57 SIGNINGtRMIT APPLICATION , <br />1,1 J z - 1, hereby authorize .1, 1 1,24,1). )/ 4 Left <br />„ <br />END 29-01 8-23-2015 Silo 101lIgation Well Permit Applicalion