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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: OPIYA. 1441 RD filcti" i`rs te At/ PERMIT WP 4: <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: G r <br />License it: 1 0 11 15(7 <br />Signature: Z5F74.. <br />ralm, <br /> <br />Expiration Date: 09/30/2022 <br /> <br />Title: Manager <br /> <br />Print Name: Tim Boyd Date: June 7, 2021 <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 />0 provided for by Section 3700 of the Labor Code, for the performance cf 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: jrztyeki-s Policy it: ta3.21 / 6017575 Exp. Date: 67/ 02,042.1 <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 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 /> <br />6-4,64tic .1; <br /> <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 />Tim Boyd , hereby authorize AA <br />Nana ac-57 I., car sod P. :1.. "Nit Nam 0.inforlzo4 zer,. <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 />ci C YiliEcissiETInotiseAkeF,Selltr.17. <br />8-1-2017 Site Mitigatior Welli6o -Ing Permit Application