Laserfiche WebLink
Se it By : Gregg Drilling & Test in ( Inc . ; 925 313 0302 ; Sep - 4 - 01 . 10 : 40 ; Page 2 ! 2 <br /> 4 . soul 9 SIAM N EARf TFCH�I � L ; fsIsS <br /> � � . sao2 a . 2i7 <br /> San Joaquin County Environmental Health Services, Unit IV Wait Permit Application Supplement <br /> JOB ApoREss:_ 6 �� o�'�.§cr°f, a iii.�..� psRrntT sR#: 2- S CC <br /> . Gxf�I7 <br /> LICENSEE? CONTRACTORS DECLARATION L( Cq) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter Q (eommenCing with Section 7000) of Division <br /> 3 of the 6ueiness and Professions Code and my license is in full force and effect <br /> Llconse , f ExpirationDsta: lA� <br /> Deis: 9 (y/O! ContractorON ^ <br /> $IQnature: - Title( <br /> ---. o <br /> Prettied name: - <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 earUficate of consent to sell4nsure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued, <br /> I have and will maintain workers' compensation 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 /> carrier�70fCt � 9006,91L Policy Number: WEZI ,r**36, 61�_ <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 the workers' compensation laws of California, and agree that U I I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shaft <br /> forthwithcomplywith those provisions, <br /> Data: R/ T �(� Signature: <br /> Printed Name: � ��• <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWRIL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (310%400a, IN ADOInON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'8 FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> ,(C•57 iirsnaad authorlsad rspresentsove), hereby <br /> Muthortte a outs � G �av fra . tt %tiL. .eCasA i Ls> <br /> to atge this San Joaquin County Well Permit Application on my behalf, I undetstand this authorization is Vaud for <br /> one (1) year end is Iltaited to the work plan dated on the front page of this application, <br /> aZt7-20001 MI <br />