Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />Cr3vn4 V %)C 5 a cscoiv•'A JOB ADDRESS: r,c r oke rikist PERMIT SR#: COV1g424 <br />PJEAA Ave Firowsoi) /lye <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect <br />Printed name: <br />WORKS. COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. k 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 carrier and policy numbers, are: <br />Carrier Cr abilc,k1--- Policy Nwnb 6 i v y 0-2-62/ <br />! certify that in the performance of the walk 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 <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shai <br />forthwith comply with those provisions. <br />Expiration Date: 614ignature: <br /> <br />Printed Name: ik <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATIOtCOVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), 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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />tAia JOLLA-- (signature ofC-57 licensed authorized representative), <br />hereby authorize (punt name)_ l'imt CV tfl4/2, k m ri Art4t,.f.ed <br />to sign this San Joaquin County Well Permit Application on my behalf. understand this authorization is lid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-02 /MI <br />Signature: <br />c9-6.)&')-`3 <br />iiATLif (-4A,01 <br />Date: * Contractor <br />License IL 51-61 D7 Expiration Date: toi i(0 <br />9 2 5 3 1 3 0 3 0 2 P • 3 IPID <br />No. 14Qh P. 3/3 <br />Jul 21 05 01:42p GREGG DRILLING <br />Jul. 21. 1U01.; 1H313PM Advanced (ieaEnv ronmental <br />* 4 <br />EHD 29-02-001 <br />022/04