Laserfiche WebLink
NOV 05 2001 11 : 51 GREGG DRILLING 9253130302 P• 2 <br /> 11/05/2001 11:19 209118 <br /> AGE STOCKTON PAGE 02/02 <br /> San Joaquin County Environmental Health SsrvicLm, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 Cade and my license Is in UI force and effect. <br /> 'I t� Z <br /> License �� `i'�� _Expiration Dale: I �l©�3l ' .. <br /> Date:_1 ) '� Contractor. <br /> Signature: - Tule: I I I <br /> Printed name: � � �� Q d ea <br /> WORKIERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-azure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of ft work for which this permit is issued. <br /> K I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the perfermanea of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy <br /> numbers are: <br /> licy J, <br /> Carrier- I 1 1 !L Q,4 �� Policy Number: 1k) 5' 'Q� y <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 this workers'compensation laws of California,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 those Provisions. <br /> Date: signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COSTOF <br /> OF TNI?LABOR . <br /> imAi �,INTEREST,ATYORHEY s FEES AND DAMAGES AS <br /> PROVIDED OR IN SECTION <br /> I. 0—,vu U )Q licensed authorised representative),hereby <br /> ,,,�1e �, f?� r !✓1 i l f✓n(� n <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand this authariz~is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. " <br /> 3-17-20001 MI <br />