Laserfiche WebLink
03113/2008 15:22 9253130 w= GREGG DRILLING�� PAGE 01 0,R0 <br />fear, 13. 2008 3:020M an d Geo E vj f0nmeItal Nn, 14,18 P. <br />San J0119Ui0 County Environmental Health Department Unit IV Well Petmlt Application `Sucp�plement <br />JOB ADDRESS: PERMIT SRAI: OJ534orr <br />LICENSED CONTRACTORS DECLAMATION LCD) <br />I hereby affirm that I ram licensed under the provlslons of Chapter 13 (commencing with sea ian 700O) of Division <br />3 of the Business and Professicn8 Codo and my licenso is in full force ttnd effect, <br />License #: _ 215 6 fes" � Expiration Date: � + I � <br />Date: l 12r Gg Contra r, 2 I f <br />Signature: <br />.Title:.(yj <br />Printed name, t <br />WORKERS' COMPENSATION DECLARATION <br />I neraby of firm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintaln a Certificate of consent to self -insure for workers' compensatlon, as provided for <br />by Section 3700 of the Labor Code, for the perforrvnce of the work for which this permit is issued. <br />I have and will maintain workers' compensotipn insurance, as required by Section 3700 of the Labor Code, <br />or the performance of the work for whidh this permit is issued. My workets' compensation insurance <br />carrier and policy numbers are: <br />Carver: de SIG /A- -l-- P011cy Number: /() 70 ?r & <br />I cattily that in the performance of the work for which this permit is issued, I shall not employ any pAr'son M <br />any manner so as to become 80jact to the worker%' oompensaatian laws of California, and agree that if 1 <br />should become subject to the workers' compensation provisiorla of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions, <br />I»xpiration Date, D I ( Signature: <br />Printed Name: <br />WARNING: FMI-URE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRI50 THOUSAND bOLLARS <br />{SlOtl,4on. , IN ADDITION TO THE COST OF COMPENSATION, INTPREST, ATTORNEY'a FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE I-AUOR CODE, <br />AUTIkORIZAT)ON EOR,3�B THAN C-67 SIGNING PERMIT APPLICATION <br />hereby autharixe (print <br />r�l <br />OfC57 lieansad authorized representative), <br />to sign this Son Joaquin Cvunty Wnll Kermit Appllestian bn my behalf. I understand this autharizatlon is vatid <br />one (t) yaar and Is limited to tho work plan dated on the front page of this application. <br />IMI <br />M 29.02-Wl <br />6'24144 <br />