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.1HN 02 20102 12. 41 GF-"GG DRILLING 82531�Q302 <br /> E oi�nor lGtr'1 11:36 209-57 ?25 P. 3 <br /> ,,:PDE5T0 ATC r.001 PAGE 03 <br /> e - f <br /> dent Joaquin C*mty Entrtronmenbt Health Serb; <br /> t:ea,Unit IV Wett'artttit Apptiestlon Su <br /> JOB ADDRESS; W_ ��� PPl�nent <br /> Sit � PERMIT SR#.- UZS,�I <br /> LICENSED CONTRACTORS DECLARATION Qi Q) <br /> I hereby affirhti that i am Acertssd under the prOVlalorls of Chapter 4(cornmehckV with Section 7pOD)of i�lviston <br /> 3 at the Business and ProfsaelOns Code and my license is In full forte and effetl. <br /> License g#: !�-7 --M�.1" ExpbWi*n Date, <br /> Dote: Contractor: <br /> Signature• <br /> retie: <br /> Printed name-. <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjtuY one Of the f0110wiat0 declarations. (CHECK ALL THAT APPLY) <br /> �I have and will maintain a certtf COW of consent to SON-Insure for workers'compensation, ae Orovrded Cor by <br /> Section 3700 of the Labor Code, for the performance of the work for which this perMit is issued, <br /> X.,have and will maintain workers'compensation insurance,ss required by Section 37QC of ftLabor Codacr the performance of the work for which this perrnit is Issued, My workers'oompensation Insurance <br /> carrier and policy numbers are,. <br /> Carrier; !4 Policy Number; <br /> I Certify that in the performance Of the work for which this permit is issued, t"I not <br /> any mwnar So as to become subject to the workers'eompensetion la" n in <br /> spree rept ernpioy any person <br /> t <br /> sneruuld become-subject of Catlfarr►la,end ubject to the warners'compensation pmvlaog of Section 3700 of the Lebon Cods,t Weal( <br /> Forthwith comply with those provisions. <br /> Date:08lgrtature: <br /> Printed Name., ��� /�/ <br /> WARNING:FAILURE TO SECURE WORKERS'COI+1PEiV8,4TRGN COVERAGE 18 UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE t'UMORED THOUSAND DOLLARS <br /> (111100.000.),IN ADDnIOit TO THE COST OF COMPENSATIOK INTEREST,ATTORNEY`$FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA00A COtg, <br /> tC-57 lkenSO4 su0mri>ed representative),horttby <br /> authorise <br /> to MOM this San Joaquin CountY WWI Permit Appiieatlor art my behalf. I understand this suthorkatiOrt is valid for <br /> one i1i Year and Is limited to the work pian edited on the frost Mage or this ape ilaaUoM <br />