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Expiration Date: <br />Title: j S of <br />Date: 3/212.0Z <br />Signature: <br />Print Name: jtatly <br />FH112P-(11 A-1-71117 <br />Cif. tilifinolinn <br />ensed Authertred Representative <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: <br /> <br />PERMIT WP #: <br /> <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: t <br />License #: id() F5 L.4 <br />WORKERS' COMPENSATION DECLARATION <br />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: rerPAILi_S'54114CF.4101 Policy #: Exp. Date: V 2-?1/4. <br />1 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 sub•ect 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 />THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />' <br />C47 L sed , hereby authorize / °Ail/ 1- e-t (e ,4 Ael.nntitarno AO deed Ageni <br />to sign this San Joaquin County w Boring Permit Application on my behalf. I understand this authorization Is valid for one year an • ited to the work plan dated on the front page of this application.