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Se -1t By : Gregg Drilling & Testim Inc . ; 925 313 0302 ; Sep - 4 - 0 + 10 : 40 ; Page 2 ; 2 <br /> � sP • 4 . flail Y 3YntA )OR OARTf TECkfj ^ L^ GIH No . 62H P 2i :1 <br /> San Joaquin County Environmental Health Services, unit IV Wall Permit Applleation Suppremant <br /> Jos ADDRE9s: 578 F'i' t ,j�_ PERMIT SR#& <br /> ickfon I <br /> LICENSED CONTRACTORS DECLARATIONL.CQj <br /> I heresy affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of 7ivislon <br /> 3 of the Business and Profemions Code and my license is in full force and effect <br /> Iicisirse Expiration Dale. <br /> Bata' 0� Contrarmrl <br /> 9160 atureo Titi dr <br /> Printsdname: 1/ e <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peijury one Of the following declarations: (CHECK ALL THAT APPLY) <br /> ,x I have and will maintain a certificate of consent to sedwinsure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Codo, for the performance of the work for which this permit Is Issued. <br /> YC I have and will maintain workers' eornpensation Insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued, My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carriers A4LtA&4be _ Policy Number: WE ZI=rn�g ("fie <br /> I certify that in the performance Of the work far which INS permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the 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 <br /> �comply with those provisions. <br /> Dab: 47 !4 /,rte_ Signature* 10:0—Aa- <br /> y, <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE iS UNLAWFUL, AND SHALL SUBJECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (3100;000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> _ . ,(C-57 licensed authorized repreaeolative), hereby <br /> " 4994 this San JOsquin County Well Permit Application on my behalf. I undet4tand this authorisation is valid for <br /> one (i) year and IS limited to the work plan dated on the front page of this application. <br /> 6t <br /> 741111416 j MI <br />