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0 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 8o9S Rr U 81 e)Co - -_ JoL�}f?1�, PERMIT SR#: <br /> 6A 9szl y <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: G��� �!st, _ <br /> License#: L.- Expiration Date: y <br /> Signature: 4zodtip- Title: Tq—fl dw- <br /> Print Name: 0&tff U �/ Date:_- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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 insurance carrier and policy numbers are: <br /> Carrier: 604 Policy#:�9r4!��WO/O Wtgwcxp. 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 Califomia, and agree that If I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> fort wt comply with those provisions. <br /> Signature: _ �-- <br /> Print Name: <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 3700 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, CV17 64! 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 s-t Ite he wooffkk plan dated on the front page of this application. <br /> _-------fL1� ne ------- <br /> EHO 29-01 8-212018 Site MlOgatlan Well Penult Application <br />