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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 730 Channel Street, Stockton, CA 95202 <br /> <br />PERMIT WP #: <br /> <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 />- <br />Contractor Name: ..f -••-! r- Co",) 7 c C/O <br />License #: 6; q5 7 7 Expiration Date: 'ii3 u (2 0 <br />Signature: Title: e <br />Date: ( altoi <br />WORKERS' COMPENSATION DECLARATION <br />hereby affimi 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 />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: Policy #: Exp. Date: 'S t <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 />Signature: <br />Print Name: <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 />- ! ( , hereby authorize ; its.,Z4 OA_ <br />Potosi Ma of Ar2veq of C47 <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 is_limited to the work plan dated on the front page of this application. <br />TI 2,( _ <br />orC.W Lotew.4,41 Aufoonfoa RoprwoorooO, <br />FHB 2g-01 8-1-9.017 Site Mitigation Well/Boring Permit Application <br />Print Name: I I