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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#: " " <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: G4rL t Fo czrvr A <br /> T�� NO2�t1�n,1 <br /> License#: <br /> Signature: Expiration Date: 5 31 Z S <br /> Title: <br /> Print Name: Mtofr2jc \s 2Ag� <br /> Date: 5 Z Z— Z <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> 1 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:_ AIgt2T7=:Ol2�> Policy#: Ztvfe—L-T1-+3 Exp. Date: to z <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, I 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 S10o,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 /> AU�THORI7ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -At <br /> A-( hereby authorize Todd Hefner <br /> —v _ <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 /> I Nur1 unN I ,� <br /> eHo 244)1 n4-2n-202s <br /> Siln Miliontinn Wnll/endno PA"11 Annliraainn <br />