Laserfiche WebLink
JAN 22 2003 2:32PM GREG DRILLING 9253130302 <br />Ui/zz"u3 WED 12:01 FAX 1 81e 0430 SECOR-SACRAMENTO <br />q-tu5,, <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Suppbrwertt <br />JOB ADDRESS:�;N� ,_ _ PERMIT SR#: -57 <br />LICENSED CONTRACTORS DECLARATION (LPD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of ttw Business and Professions Code and my license is in full force and e. act. <br />License #: Expiration Date: <br />Date: <br />Signature: <br />Printed name: <br />COMPENSATION DECLARATION <br />IPM <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintaln a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Cade, for the performance of tha 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 tnsuranca <br />carrier and policy numbers are: <br />Carrier: � �57�� Policy Number: <br />XZ? 1 <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 beoome subject to the workers' compensation laws of California, and agree that It <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. l <br />Date. /-i2:f 2 Signature- <br />Printed Name: <br />WARNING: FAILURE TO SECURE WOAKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S100,000.), IN ADDMON TO THE COST OF COMPENSATION, INTEREST. ATTORNEY'S FEES, AHD DAMAGES A9 <br />PROVIDED FOR IN SECTION 9708 OF THE LABOR CODE. <br />I, (epi (slQnature ofC-67 Itcenaed authorized representative), <br />haraby authorize (print na+ne)/ ,ZZ4 u S n-2 <br />to sign tits San Joaquin County Welf-PermR Appllcatlon on my behalf. I understand this au"rizatfon la valid for <br />one (1) year and is fla*ed to the work plan dated an the front page of this applIcation. <br />7-20001 MI <br />p.2 <br />IQ 002 <br />