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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 724 Grant Line Road, Tracy CA <br />PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LCD) <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 />License #: 680227 <br />01/20/2015 <br />Date: <br />Exp Date: <br />11/30/2015 <br />Contractor: ADVANCED GEOENVIRONMENTAL, INC. <br />Signature: Title: ti e__�ocl <br />Print Name: ROBERT MARTY <br />WORKERS' COMPENSATION 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 />X 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 />( 9AV,kLF,?S PnCPe�TJ CA_,6-o—?L.-ry (0.7 <br />C <br />Carrier: 0,me>r Policy Number: CV's' 4 )t,) ! 2 L• CP <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California, <br />and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: /17 ZG 1 S Signature: 1--�� <br />Print Name: ROBERT MARTY <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000 IN ADDITION TO THE _COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />1r9M..M.2+ - ate .... . , , .. r <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I <br />hereby authorize (print name) <br />(signature of C-57 licensed authorized representative), <br />, to sign this San Joaquin County Well & Boring Permit <br />Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br />plan dated on the front page of this application. <br />EHD 29-01 07/28/10 WELL PERMIT APP <br />