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Sent By : Gregg Drilling & Testing, inc . ; 925 313 0302 ; Sep - 4 - 01 _ _+ 0 : 40 ; Pne 2 ! 2 i <br /> � eP • a • Plit, 1 9 IMAM JR EART- h TFCRNUL DIES No o3p6 P . i/ 2 <br /> San Joaquin County Environmental Health Services, Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS:-. G �3 O � ' t /�.fr� PERMIT SRIF: - " � f q `% I <br /> G�lr� <br /> LICENSED CONTRACTORS DECLARATIONL( Cpl <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000) of Division <br /> 3 of the AUSiness and Professions Code and my license is in full force and effect <br /> Lkxrlse #: _ Expiration Date; <br /> Date; r y 471 Contnacmr, <br /> Signature: + Tttte(, �� <br /> Printed name : T - <br /> IF <br /> WORKERS' 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-Insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit 14 laeued. <br /> 1 have and will maintain workers' compensetton Insurance, els required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued, My workers' compensallon Insurance <br /> canter and policy numbers are: <br /> Carrier�7pt � f, l�l2( Policy Number: Lf+' F i .f`/9(a, <br /> I certify that in the performance of the work for which thls permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that N I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shalt <br /> forthwithComplywith those provisions. <br /> Data: '9 � T �� signature: <br /> Printed Name: 4S415700 �... 1f�Y' <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 /> (Et00,4004, IN AUDITION TO T11E COSY OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9700 OF THE LABOR CODE. <br /> r <br /> it �if�JP �" ,'y1�° ,,(C•57licensedauthorizedmprasonbilive), hereby <br /> autharin ,LPG ✓' ! e� yJ-e,._ oG L.�, 1� v Lr"at.� N. %CeG, ..e (r,�Jf�,� Jc <br /> to elan this San Joaquin County Well Permit Application on my behalf. I Understand this authorization Is vend for <br /> one (i) year and IS limited to the work plan dated on the front page of this application. <br /> 6*17 2000 1 MI <br />