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----------- <br />L <br />JOBADDRESS ml 6, <br />J PERMIT SR #: <br />0 a #A 9 10 - 11161211 <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 815620,5:,, Expiration Date: 12/31/2016 <br />Signature: Title: 4 <br />Print Name: Date: -2/ <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 />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 subje to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />hwith 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 OR CODE <br />I Oil <br />Lk,,o-.d AW -id Rp—wivo hereby authorize A" <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 />Signatum of C-67 Liewumd Authodud ltep—tmWe <br />EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />