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it <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7 �S rar.r aJp Qd • 5{'�I��,C/� 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: q%U(C D(t11t (l) <br /> License#: W1 C1 Expiration Date: <br /> Signature: Title: CIE <br /> Print Name' �J)r n ,P/ Date: 1"1 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> 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 workers' <br /> of the <br /> * Labor Code, for the performance of the work for which this permit is issued. My wokers'r <br /> compensation insurance carrier and policy numbers are: I� <br /> Carrier: UQSIC0 Zr2A/(t4CC C.O- Policy* Qwtz 3Zj 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 t . orkers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> n/ forthwith comply with those provisions. <br /> Signature: v <br /> Print Name: l 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 /> ASADDITION <br /> TO THE COST OF COMPENSATION, EST, ATTORNEY'S FEES, AND DAMAGES <br /> PROVIDED FOR IN O aN 06 OF THE LABOR <br /> AUTHORIZATION <br /> T FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> tUG(� 1 VGU�P� hereby authorize <br /> I p,., ,1„lm�mnw Inl <br /> YnevlCiJ ku, 1 Pepn,M 1 ! <br /> to sign this San Joaquin County Wel &Boring Permit Application on my behalf.I understand this <br /> authorization Is valid for one year nd� imitad to the work plan dated on the front page of this application. <br /> �ALkmlN puE,etl,lG epwminh< <br /> Site Mitigation Welgaoring Permit Application <br /> EHD 29-01 B-1-2017 <br />