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0 • <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: SCJ9S Rl fJ U-1anGO A ._`JLuw, PERMIT SR#: <br /> CA, 95z1q <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 Califomia Busines/s and Professions Code and my license is in full force and effect. <br /> Contractor Name: Grey ��stly <br /> License#: L Expiration Date: r[ S( /e' <br /> Signature: ^^ // - _ Title: Opera&(& / znnG�ca' <br /> Print Name: T_ <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 /> 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 /> Labor Code, for the performance of the work for which this permit Is issued. My workers' <br /> compensation insurance carrier and policy numbers are: � - <br /> Carrier: f4?04 Policy M: '& I�G�O �Eip. Date:_ <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 /> forthwi comply with those provisions. <br /> Signature: <br /> Print Name: (. 7hrr/ ce4e,/ <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, ATTORNEY'S 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 /> I, ��✓�fG/1�/ hereby authorize <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 he w It plan dated on the front page of this application. <br /> I Z� <br /> p .a <br /> EHD 2"16-23-2018 Site M111gation Well Pamit Applicellon <br />