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EHP 29-01 07120/10WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 16500 Clifton Court Road PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License : 690227 Exp Date: 11/3012013 <br /> 1/21/2013 Advanced GeoEnvi-ental Inc. <br /> Date: Z7 Contractor: <br /> Signature: Title: President <br /> Print Name: Rcbert Mary <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 /> ar � <br /> ' <br /> Carrier:'�e1t4% ?n�`t CASV4S 4wp cy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code�1I shall forthwith comply with those provisi <br /> Exp. Date:—I()— t ( ' Za1 l Signature: <br /> Print Name: Robert Marty <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST of COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZTION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Robert Matt, signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Daniel villanveva to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> 's <br /> EHE 29-01 o7/20110 WELL PERMIT APP <br /> I <br />