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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:._�� 5/ _�� td.laQ r .Sf,�. Sfi Noil,s..Ii 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:_ TE G <br /> License#: _7 _(Q_g__- Expiration Date: b_S�3 � ao <br /> Signature: Title: �' J <br /> Print Name: iv]a r kJ:g tT L a k _____ <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 /> 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:_Mari ISo r Policy#:z�?_Wjtcl y"" Exp. Date:_/Q�Qy�zw? <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 $1100,000, 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 p- A rp ya`- <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf. 1 understand this <br /> authorization is valid for one year7;q7 <br /> dated on the front page of this application. <br /> -— -,nnms <br /> EHD 29-01 8-1-2017 Site Mitigation WelitDoring Permit Application <br />