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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: - PERMIT SR #: <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 /> License #: t �— i Expiration Date: <br /> Signature: _____Title: �ie j <br /> Print Name av rD 1 - Date: <br /> WORKERS' MPENSATION 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 /> E3 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 /> Cep(\ Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation in nce carr er and policy numbers are: <br /> i' <br /> Carrier: JV�_k1j Policy #: 9 11 ?" 1_ / Exp. Date: <br /> 1 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 to11he1workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisiorls of Section 3700 of the Labor Code. I shall <br /> forthwit comply with those p ovisions. <br /> Signature: <br /> Print Name <br /> WARNING: FAILURE TO SECURE WORKERS 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 FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHOMZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> VU, <br /> � i <br /> /i( � here!i '�J authorize <br /> Yerm d CdT VicenteC Aufhonze�Rsprexnfairvel print N of A.1h. -Agent <br /> to sign this San Joaquin Coun Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one y ar and is imited to the work plan dated on the front page of this application. <br /> i1' 1 <br /> ,gneture a t ansae ufnp i Repesen r <br /> t <br /> EHD 29-01 6-23-2015 Site Mitigation Well PeTnd Application <br />