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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT WP #: <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: tsQrb(�,, -T�L <br /> License#: 01 -1-2,(I Expiration Date: ?Z-3i 1.2..v-2—r <br /> Signature: Title: d W nrc/ <br /> Print Name: �P � ( Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 /> 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 /> Carriers��k- AV'^ INS Policy#: !FZ) 47L—�xp, Date: d- /S2� <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 <br /> should become subje;?, <br /> workers",compensation provisions of Section 3700 of the Labor Code, I shall <br /> hwith comply with those provisions. <br /> Signature: <br /> Print Name: S a <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 /> I ,un �5 d " JR/ CZAJ �x , hereby authorize, 4 (f.CJ� <br /> NameLicensed Authorized Rep aenl w �Fnnt sma Autha ed Agent <br /> to sign this San Joaquin County Well &Boring Perm)t Application on my behalf. I understand this <br /> authorization is valid for ane year and is limytedtto the)*6rk plan dated on the front page of this application. <br /> �.t....c �..a .: w•<s.netw. <br /> S1te Wk\q 131\W P&Muf ng P e-n%k AppNcaGor\ <br /> EHD 29-418-1-Vl <br />