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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7-Eleven#19976, 1399 North Main St., Manteca, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensee' under the provisions of Chapter 9 (commencing with Sectior 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Licensa#: q S 3 II <br /> (o Exp Date: 10 I3[lip 14 <br /> Date: _ 5-�Z� LO It-{- Contractor: ?�KXa <br /> ,./ <br /> Signature: _/ ---- /�' Title: ]RD �L�pp=ro*,-so Q-) <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations* (check one) <br /> I <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as i <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:_ - -'C,h�fY}Qr— r"lSV olicy Number: VUG R 319�3Zo <br /> 1 certify that in the performance of the work for which this permit ;s issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shal!fortl^with comply with those provisions. <br /> Exp. Date:___� �s Zc7l c� Sig nature• _rte-�-3 <br /> Print Name: til rt amedy r��__ <br /> WAkNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $103,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOP.CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 1��►'SJI��_� �'(__ - (signature of C-67 licensed authorized representativel, <br /> hereby authorize(print name) Stantec Consulting , to sign this San Joaquin County Well & Baring Permit <br /> Application on my beha!f. I understand this authorization is valid for one year and is limited to the work 1 <br /> plan dated on the front page of this application, I <br /> EhD 29-01 05109/12 WE:L PERMIT APP <br />