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San Joaquin County Environmental Health Department <br /> WELL$ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2085 East Fremont Street, Stockton, CA PERMIT WP M <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 /> C1 License#: O(n 56 gj Expiration Date: 5 31 Z S' <br /> Signature: Title: RA19 <br /> Print Name: M&r22 c 5;(C PgAk< Date: S— Z -Z Z <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 /> 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:_ 14Aa7-i=r7eLD Policy#:R-L"Yi/ 9`(�3 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' compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize Todd Hafner <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 /> 1 •Nn unN , a• ppn11 <br /> EHo 2"1 04-20-202.1 <br /> __ S"A Mi0n30nn WnIIIRminO PAMR Annliralinn <br />