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San Joaquin County Environmental Health department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:5��7 `V eG .c.r . 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 /> Contractor Name: <br /> License#: _ C S>l; Expiration Date — - 2— <br /> Signature: ,�� Title: ofC <br /> Print Na " . �( "Tip.✓-- D Date: <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 nUrnbers are: <br /> Carrier: f,W_� r,lrv'i� Policy # : ` A3 �—Z' Exp. Date:_ ^._ _ <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 /> AUTHOR"TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. hereby authorize < • .^ <br /> --- ---- <br /> r N i csi Ko..e onia Naprvwntathn Pmt r+nnre d AWnaized Hanoi <br /> to sign this 3,a. Joaquin County Well &Boring Permit Application on my behalf. I understand this <br /> authorization one year and is limited to the work plan dated on the front page of this application. <br /> RED RFD <br /> EHD 23-01 41,2023 Site Mitigation Well!Boring Prermit Application <br />