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• 0 <br /> San Joaquin County Environmental Heaiti Del:artment <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 19107 Christopher Way (LAS-1) Lathrop, CA 95330pl=R IT SR #: 0673741 <br /> T Ooy3y` 3 <br /> LICENSED CONTRACTORS DECI.��F:: <br /> I hereby affirm that 1 arr licensed under the provisions of Chapter 9 (c),nmenc Ing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license Ls in full force and effect. <br /> Contractor Name: �`� \;I�}��, �( �(lP►1 __ <br /> License#: _Expirati,:n Date OA S)r t %1v 1v <br /> Signature: Title: }- <br /> Print Name: <br /> _Date:_I'��_ 1 � <br /> WORKERS' COMPENSATION DECLARA TI DN <br /> I hereby affirm under penalty of perjury one of the following declarations ;ch-srck one) <br /> I have and will maintain a certificate of consent to self-insure !71 Workers' compensation, as <br /> [] provided for by Section 3700 of the Labor Code, for the perfc•rrance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as rEquireJ by Section 3700 of the <br /> Labor Code, for the performance of the work for which this pc-mit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy#:R -_I�� xp. Date: Qee, lC 20�S <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 la-o of Callfornia, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 f the Labor Code, I shall <br /> forthwith comply with those provision:: <br /> Signature: <br /> Print Na <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE: IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND C VIL 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 PI: F MIT APPLICATION <br /> I. hereby authorize <br /> sig is San Joaquin County Well & Boring Permit Application of i niy behalf. I understand this <br /> authorization is valid for one year and is limited to the work plan dated or tt a Front page of this application. <br /> EHD 29.01 6-23-2015 Si a MI!gation Well Perrnit Application <br />