Laserfiche WebLink
0341f/20140 '1UNT. ""9253130302 GREGG DRILLING PAGE 01 04 <br />"Nar. 1�. 2008 342FN1 A6vanced GeoEnvironmenral No, '428 P, 4 <br />iuhtl/3f lv <br />San Joaquin County Environmental Health Department Unit IV Woll Permit Application Supplement <br />/ <br />JOB ADDRESS: CS _1AT`ee� PERMIT SR#: 955(lor"( <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I arr licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Coda and my licenso is in full force and effect. <br />License #; )J_i Explration Date: (�Z i <br />Date: I f a� Contra r:_hr1'Jrf,3_Q <br />Signature: I Title: S 2 <br />Printed name: )Cl <br />WORKERS' COMPENSATION DECLARATION <br />horoby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have 4111d will maintain a Certificate of consent to self -insure for workors' compensation, as provided for <br />by 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 Sauflun 3700 of the Labor Code; <br />or the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier:JrIG� dL -1" 1`011cy Number: 6,'51 () 7 l <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any perton in <br />any manner so as to become eubject to the workers' compensation IpwO of California, and agree that if I <br />should become subject to the workers' compensation provision$ of Section 3700 of the Labor Code, I shall <br />forthwith cornply with those provisions, <br />5xpiration Date: / (� Signature: - <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTFRFST, ATTORNEY'8 FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LAEOR CODE. <br />AUTI IIDRIZAT)ON EOI�TNER THAN C-67 SIGNING PERMIT APPLICATION <br />hereby authorize (print <br />signature ofCS7 licensed authorized ropresentatiivee), <br />V01M--7A /q X1.1 01h 61,4 (r r <br />to sign this San Joaquin County WRII permit Appllcatlom on my behalf. I understand this authorization Is valid <br />one (1) yGsr And 19 limited to the work plan dated on the front paea of this appliwitlan. <br />F -M 24.02�wf, <br />6/22104 <br />