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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:23?S:Z 41 Pl I7 U/a a 99 PERMIT WP#: <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: W Co D Whit D DR/mot i�1Nr' — <br /> -- <br /> LicenseM a57- 7/0074 —Expiration Date:_?-• 31• 19 <br /> Signature: � !Title: res,61' 1d <br /> Print Nama: f' Date: 1 o�;Z=0 I F� <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 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 /> o 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 im rance carrier and policy numbers are: <br /> Carrier: .I / r/iw LD) tG Pouoy#: �503 02/_t 8 Exp,Date: 01 o i9 <br /> WO of <br /> I certify that in the performance of4Fte work for which this permit is issued, I shall not empty 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 to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with ose provisions. <br /> Signature: <br /> Print Name: WaPi <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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, ATTORNEYS FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (���e W o01>wIn-e� hereby authorize S— �"/ G <br /> to sign this San Joaquin County Wen&Boring PernitApplicatlon on my behalf.I understand this <br /> authorization Is valid for one year end is limited to the work plan da on the front page of this application. <br /> EH0 2"1 81-2017 s"mfts m vwmkrkv Pwn*APPimho n <br />