Laserfiche WebLink
05/1512007 12:42 9253130' GREGG DRILLING ' . PAGE 02 �r0 <br /> May. 15. 2807 '8:46AM Addvaarced NQ. 8600 P. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well permit Application Supplement <br /> JOB ADDRESS: 2Ad Weat H rain Wa PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONLCD <br /> I hereby affirm that I am licensed Under the provisions of Chapter 9(commencing With Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force end effeck <br /> License#; - Expiration Date: <br /> Date, COrlt - <br /> Signature: y Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations; (CHECK ONE) <br /> Thain and will maintain a certificate of consent to self-insure for workers'cop gansation,as provided Tar <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> �l have and will maintain worhers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this pemtit is lesued. U y workers'compensation insurance <br /> carrier and policy numWrs are,. <br /> Carrier: Policy Number PAIM-C _. .. <br /> I certify that in the performance of the worts 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 I of Cal forma, and agree that ff 1 <br /> should become sul;iect to the workers'compensation provisions of Section 37GO of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Elate, x Ignature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE- ORKFAS'COMPENSA ICH COVERAGE 15 UNLAWFUL,ANO SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN125 UP TO ONE HUNdRIED THOUSAND DOLLARS <br /> 19I+MIPNJ� IN ADDITION TO THE 003T OF COMPENSATION,INTEREST,A71`0111NEY'5)Fr%9,AND DAMAGES AS <br /> PROVIDED FDR IN SECTION PTi41B OF THE LABOR CGDE„ <br /> AUT OR T F THAN C-57 SIGNING PERMIT APPLICATION <br /> I /�� RIpnature OM-Krlice rmed authorized mpresentetive), <br /> hereby authorize print narnel /// Cd I�Gt AJf "lT <br /> W 61911 U114 0011 Jud4virr OVu"lr W011 Per„irl Appn"101f an any tail�alfl tmderotand Chia authorization is valid for <br /> Dnp I4 year and Is Urnrted to the work pian dated on the front paha of this epplication, <br /> LI.3-M31 MI <br /> " trHa z9.oa.001 <br /> 6fM7 4 <br />