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x �^ <br /> M <br /> z_ <br /> San Joaquin County Environmental Health Department _ <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL M o <br /> JOB ADDRESS: 1?•1� A 1.6:-eN!4 U PERMIT SRO: <br /> T2c-G(rZv? CA 9$:Z-C C <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: _;/}��^E S M bG�E s,,3u A'C- ?I��f�i��' %Z /�il/�c r>l-�E 5 i)A/ yG <br /> License#: 7 - < 5- LExpiration Date: March 2018 <br /> Signature: -f �..1_ _ Title: - <br /> Print Name: ,rf�S M l�f?ES/3 Ll __._ Date,- LC 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 /> provided for by Section 3700 of the Labor Cade, 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 carver and policy numbers are: <br /> Carrier: American Interstate Policy#- AVWCPA2557252016 Exp.Date: 12/19/2017 <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 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 /> - <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 /> EHD 29-01 6-23-2015 Site Mi*jabon We4f Permit Appicabon <br />