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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:434 E. Dr. Martin Luther King Jr. Blvd, Stockton PERMIT WP M <br /> LICENSED CONTRACTORS DECLARATION <br /> 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: G re f.2 lve-,141;p <br /> License* C S 7 /D (� _ Expiration Date: (?/3n /2( <br /> Signature: ^/ Title: <br /> Print Name: C.�l�'/-/ �p"Ce�'Jv- Date: <br /> WORKERS' COMPENSATION 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 /> compensation insurances carrier and policy numbers are: <br /> Carrier:a-LT S,,ot��a/7�� Policy#:wG��?- il Exp. Date: B( 3///";> <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 to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith c mply with those provisions. <br /> Signature: <br /> Print Name: �"iJ I1L!/7 ^ - -------- - — - <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 /> hereby authorize <br /> l�r,W Ilrnl.ut]je1r...r,1.li.t -- - — Anl ll.i,wd Aulw4.Y Aywl <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year and la�tork pl?n dated on the front page of this application. <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br /> Quick Notes Page 3 <br />