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San Joaquin County Environmental Health Vvpartment <br /> WELL.&BORING PERMITAPPLtCATIoN SUPPLEmr=NTAL <br /> JOB ADDRESS: 950 Stewart Road PERMIT'WP M. <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 game: Bradley and Sons Drilling and Pump Systems <br /> License#: 414178 _ Expiration Date: 3131/2024 Y <br /> Signature: <br /> Print name: <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the'following declarations:(cbecR one) <br /> 1 have and will maintain a certificate of consent to self-insure for workers'compensation,as <br /> 13 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: Berkshire l t�iaway Policy#: BRLdC329428 Exp.[late:__-1/1/202 <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 370i1 of the Labor Code, 1 shall <br /> forthvrith comply with t e provisions. <br /> Signature- - <br /> Print Name: —A C4� <br /> -- — -- - — <br /> WARNING: FAILURE Tt3 SECURE WORKERS' COf PENSATION COVERAGE IS UNLAWFUL, AND SHALL. <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL. FINE-9 UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYS 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 /> e— ,hereby authorize <br /> A.W. �rFG�p z:�v V r griG�S <br /> T W 5l LK-1.1 Y 1✓i �minNlY vrfut�✓A�s0�4ni-_._ _ �._. <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 /> EHp 29,01 04 07-2022 Site rAligiAmi wa:lMaing Permit Applinihm <br />