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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> � A <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 : <br /> License # : ` > - Expiration Date : <br /> i <br /> Signature : Title : ��� 1 Z ::)S* " <br /> Print Name : Dater <br /> WORKERS ' COMPENSATION DECLARATION <br /> 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 /> 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 : (Oo,,l< Rive ► ) ►15van ( Q Policy # : 70W015Jg7J Exp . Date : 1010112 I <br /> CQynpUn <br /> certify that in the performance of the wbrk 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 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 : 3AO <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 , 0003 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 , , hereby authorize <br /> Name of C -57 Licensed Authorized Representative Print Name of Authorized Agent <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 /> Signature of C -57 Licensed Authorized Representative <br /> EHD 29- 01 8 - 1 -2017 Site Mitigation Well/Boring Permit Application <br />