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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: Ss / _�. .S (A Ld �� PERMIT WP #: V/ P 0 j K 9� `% <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 />r)11i►� <br />License #: lZo go Expiration Date: Lfho Zol K <br />Signature: -i"— �. ) -r Title: `; 1'C.- I' A O <br />Print Name: �Gl>' l1107 ' �� �L1 �VDate: � <br />WORKERS' COMPE ATION 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 />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 ��urance car ier and policy numbers are: <br />l 1' Policy #:1� C)� 103— <br />Carrier: I / Exp. Date: <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'_ eo7►�pensation prvisions of Section 3700 of the Labor Code, I shall <br />�f�rthwXth comply wit)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 />to sign this San Joaquin Cou <br />authorization is valid for one year <br />my behalf. I understand this <br />the front page of this application. <br />EHD 29.01 B-1-2017 Site Mitigation Well/Boring Permit Application <br />