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Sent By: Gregg Drilling & Testing, Inc. ; 925 313 0302; Oct-27.99 14:50; Page 2/2 <br /> ti... �. <br /> San Joaquin County Environntanbt Hea)th:8ervices,unit IV Weft Pea"Application gt4)Wement <br /> JOB ADDRESS: L-7o) l,Jr/soy (,�a� ,�Iv�k, JPERMIT' Sft: 02-100 <br /> LICENSED CONTRACTORS DECLARATION (L_ CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(oornmencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License# `><,%.SI(a.!5 Expiration Date !�Z:a <br /> Date 1,0 2.7 7 Contractor. C7� �f��� 7^al.sbr!)S Tints.,. <br /> 0 <br /> Signature: Title:_0Qerc_-Yf <br /> Pdntied 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 certiftate 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 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- ll <br /> Carrier: i�Q ) GAP Policy Number, <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 it I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Date: 4 z7 signature: .� n -►� <br /> Printed Name: C-'t�fShQ✓ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND OOLLARS <br /> (5100.0o0.),IH ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> ROIIIDED FOR IN SECTION OF THE LABOR CODE. <br /> I (C-S7 licensed authorized representative).hereby <br /> :a<a,ortr. s ✓6✓atr,�,est 5re M c*-b ,o 1 e L <br /> to sign this Sen Joaquin County Weil Permit Application on my behalf. I understand this authorization Is valid for <br /> one 1 year and Is limited to Iho work plant doted on Ow front page of this application. <br /> Z d HOaJ KvZO' Ll 6156t-9Z-01 <br />