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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: $ IU!, ' C } 1� , PERMIT SR#• <br /> LICENSED CONTRACTORS DECLARATION <br /> i <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: CB&I Environmental&Infrastructure,Inc. <br /> License#, { 81562 Expiration Date: 12/31/2016 <br /> Signature: Title: APO <br /> Print Name: � /�, DG Q Dater_/f 2evl <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 insurance carrier and policy numbers are: <br /> Carrier. Zurich American Policy : 5821850-03 Exp,Date: 07/01/2016 <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 b come subject to the workers'compensation law of California, and agree that if I <br /> should become subj to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> with 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 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 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 Is limited to the work plan dated on the front page of this application. <br /> P <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />