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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:IN23 �¢t{t} oR�_1rSL Z Oc.�T?'� _ PERMIT WP *: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 700 0) of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: WESS CORS -T £xptn CnYiu-,J _ I <br />License#: O Expiration Date:Ol I31 1 a a 10 <br />Signature: Title: �lPJ G�ak, <br />Print Name: _ v26111,- J e- i7G� Z Date: <br />WORKERS' COMPENSATION DECLARATION <br />herebv 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 />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 N: _ Exp. Date:_ <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 />�iorthwith co ly with those provisions. <br />Signature- / -------- <br />Print Name' ---- <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 />i, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />7d/re<) .e)MA£ <br />to sign this San Joaquin County Well & B Ing Permit Application on my behalf. I understand this <br />authorization is valid for one year an mite o thewgrk an dated on the front page of this application. <br />2Y47 &1-2017 Site Mitigation VHF faring Pemiit Application <br />`J <br />i4 <br />