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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT/APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: --_ �rZ PERMIT SR#: C 07 �G <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 license is in full force and effect. <br /> Contractor Name: <br /> * -- - - -— <br /> License i <br /> / Expiration,Date: <br /> Signature: - /1. � 0J, -� Title: <br /> Print Name: ! ' f)j, �� (,' Date: <br /> WORKERS'. OMPENSATION 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 /> co ensationrir}surance,carriercnd policy numbers are: <br /> Carrier: V -�` { - '�.� Policy#: t- �� ( Exp- Date. f �, <br /> ` <br /> i <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 law of California, and agree that if I <br /> should become subject tq workers'compensation rovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply wh those provisions. <br /> Signature: - <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' C MPENSATION 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 FOIA IN SECTION 3706 OF THE LABOR CODE <br /> A THORIZATION.FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> , <br /> l n T <br /> / /� <br /> o 'r �._." hereby authorize I i '�,;_j.r (�I (.I. <br /> Nome of CjUcd Aulhorlaaflative ' P17nt Name of > riactl qA,ant r [ <br /> to sign this Saq Jp n County�Nell & Boring Permit Application on my behalf. i understand this I <br /> authorization is valid for one year and,is limited tp the work plan dated on the front,�age of this application. <br /> a , <br /> U, <br /> • <br /> END 29-016-23-2015 Site Mitigation Well Permit Application <br />