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it <br /> i <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 241-520-010-000 PERMIT WP#: 0 <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.' Gulf Shore Construction Services,Inc.,dba GS Exploration <br /> License#: 964224 Expiration Date: 08/31/2025 <br /> Signature: Title: Vice President <br /> Print Name: josh Fayter Date: 03/04/2025 <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: Bridgefreld Casualty Ins. Co. Policy#: 0196-57026 Exp. Date: 12/19/2024 <br /> 1 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 /> fo comply with those provisions. <br /> Signature: <br /> Print Name: josh Fayter <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 /> t AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, fosh Fayter —, hereby authorize )oe Ztlles(IQetnfelder) <br /> ' 14mee1 C31 LR flSWAUftlhfd Repn,enlafte Pdnl Ham,olAult panl <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf.I understand this <br /> authorization Is valid for one Y;7d is limited to a-wo Ian dated on the front page of this application. <br /> EHD 29-01 04-07-2022 - Site Mitigation WeNBoring Permit Applicalion <br />