Laserfiche WebLink
- nu«r<Gvo iG:1G yzasijeGREGG DRILLING 1 i ( w PAGE 02 <br /> I <br /> ti G <br /> San Joaquin County Environmental Health Department Unit IV Well Permit ApplicatioCn S ppl Ment <br /> JOB ADDRESS: 1717 south Center Street PERMIT SR#: O/ a l 1, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Suslnesss and Professions Code and my license is in full force and effect: <br /> Licensee. `ice' Expiration Date: i'✓���polo <br /> Date: Cc '1 l T�df11 �li7L . <br /> Signature:' Tftle: <br /> Printed name: <br /> WORKE116' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ona of the following decteratlons: (CHECK ONE) <br /> 1 _I have and will maintain a cartlffcate of consent to self risure for workers!compensation,as provided for <br /> by Section 3700 of the Labor Code, for the pe,fon,once of the work for which this permit Is Issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> f— for the performance of the work for which this permit is issued. My workers'compensetlon Insurance <br /> carrier and policy numbers ars: <br /> Carrier. policy Number. oc;, <br /> I certify that in the performance of the work for which this permit is issued,I shalt not employ arty parson in <br /> any Manner so as to become subject to the workers'compensation laws of Callfamis,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with thazaaiprovisions, �-- <br /> 6ipirrtion Dale: `� I �V Signature: , <br /> Printed Name:. C rt ca'I Wih yY�� 1�Y <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALT.SUBJECT <br /> { AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> !E (S9 g0,00a.j,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S F£E3,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3705 of THE LABOR CODE. <br /> I ZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (slgnature ofC-SJ licensed authorized representative), <br /> herebyauthorizs(prlrrtname).�Stp4'�1 A«dc�s>.. <br /> to sign this San Joaquin County Weil Permit Application on my behalf. 1 understand this authorization is valid for <br /> i <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> B-20-02 1 MI <br /> EFIU 29-02A01 <br /> Forma <br /> , <br /> i <br />