Laserfiche WebLink
11/0:7/2007: 12: 01 9253130302 GREGG DRILLING PAGE 03 <br /> rvuv-er-�ee'r 12 G5 CAMBRIA 1707 935 6649 P.03i05 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Allyu , c_"U,a^fti2s� PERMIT SR#: <br /> `b LO W . 0^&-000.., W 11160 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the proviNcins of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Profeaslons Code and my license Is in full force and effect. Q <br /> License#: G's7 ' Ty 'W 57 Expiration Date: <br /> Date: ntractor: I n7n /7 G <br /> Signature: /` Title: U �CC. <br /> m <br /> Printed nae:—f h I r w 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of parjury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to seWinsure for workers'oornpensation, as provided for <br /> by Section 3700 of the Labor Code,for the perfonranoe of the work for which this permit is issued. <br /> A'haveand will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> r the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy are: 1- <br /> Carrier: Sl/l�p(k I l Policy Number. �I V�Q,- <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compena"on provisions of Section 37 0 of the Labor Code, 1 shall <br /> forthwith comply with those rovislons. <br /> Expiration Dater D Signature: <br /> Printed Name: G1/J <br /> WARNING:FAILURE TO SECURE WORKERS,COMPENSATION COVERAdE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN GECTION 3706 OF THE LABOR CODE <br /> OION F ori THAN C-Z7 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC.67 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 8.29.02/Ml <br /> EM 29.02-001 <br /> 020 <br />