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San Joaquin County Environmental Health Department <br />WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: /` PERMIT SR #: <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 lir--n--,P- is in f ill fni-rA nerd nffor+ <br />Contractor <br />License #: <br />Signature: <br />Print Nam( <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 />com ensati surance rrier and policy numbers are: <br />Carrier: Policy #: L `� -) V C - Exp. Date: D ) <br />I certify that in the performance of the work for w ' this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the w rkers compensation w of California, and agree that if I <br />should become subject to workers' compensation ovisions of Sectiol 3700 of the Labor Code, I shall <br />�i-prthwith comp with those provisions <br />jj a i <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 `l.� CV — (L-\ V1 co <br />to sign this San Joaquin Counq Well & Boring Permit pplication on my bhalf. I t nderstand this <br />authorization is valid for one ye r and is limy9d to the wor plpn dated on the ront pa9A of this application. <br />EHD 29-01 6-23-2015 1 <br />Site Mitigation Well Permit Application <br />