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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: PERMIT WP <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 />0 <br />Contractor Name: OX3)(C- Dri I n q T (AL <br />License #: C10 91 / I Expiration Date: \\ - 30 - VI <br />Signature: "1--' Title: C—e() <br />Print Name:/ \ UGA IdC\J\IV\ Date: \\ -1Z <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: \nig., 111'S<C\fIC.Li Policy #: VJt..JC,3/ (Y1 -2 Exp. Date: 1 1 <br />1 <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 subje ://io workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />UPrint Name: CA.(\ NCi16(\ <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 />1‘0 U U /O\ , hereby authorize <br />NAme of C-S? Localised Autl tsro/o Represent-111,e Pruit NWT. a Authorized Age,. <br />to sign this San Joaquin County Welp& Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is4hnited to the work plan dated on the front page of this application. <br />1,7 Signature of C-ST Licensed Authorized <br />II Repreteniatore <br />END 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application