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San Joaquin County Environmental Health Department <br /> WELL & BORiNG PERMIT APPLI:ATION SUPPLEMENTAL <br /> JOB A3DRESS: 7-Eleven#19976, 1399 North Main St., Manteca, CA <br /> PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I art, licensee' under the provisions of Chapter 9 (commencing with Sectior 7000) of I <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Licens: I <br /> #: R S 3(p Exp Date: I O/3l ilk 1 t-,L <br /> Date:_ s�Z� ZO Imo}-_ Contractor: <br /> Signature: /.._ —_ Title: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> II hereby affirm under penalty of perlury one of the following declarations- (check one) I <br /> I I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> orcvided for by Section 3700 of the Labor Code, for the <br /> oermit is issued. performance of the work for which this <br /> have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> _abor Code, for the performance of the work for which this permit is issued. My workers' <br /> (:Ompensation insurance carrier and policy numbers are: <br /> I:arrier:-2-o-10 <br /> h Armpvi caj-) olicyNumber: WGg3t9 3Z0 <br /> I certify that in the performance of the work for which this permit ;s issued, I shail not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> find agree'that if I should become Subject to workers' compensation provisions Of Section 3700 of <br /> the Labor Code, I shal!forthwith comply with those provisions. <br /> Exp. Dale: <br /> -- -- -- ----- Signature;�-- / <br /> Print Name: (2,k(`1 g7rn471 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENAL:IES„4D CIVIL FINES UP TO $103.000, 44 ADDITION TO THE COST OF COMPENSAT:ON, INTEREST, <br /> ATTCRNEY'S FEES,M 2&AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOP.CODE. <br /> 'AtTT710IWFOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> aq <br /> (signature of C-67 licensed authorized representative), <br /> hereby authorize(print Warne) Stantec Consulting , to sign this San Joaquin County Well r# Boring Permit <br /> Applicatic►n on my behalf. I understand this authorization is valid for one year and is limited to the work i <br /> plan dated on the front page of this application. <br /> Er029of 0!/0911: �-----`------ <br /> !LE!f PF pAAT eo^. <br />