Laserfiche WebLink
PAGE 02 GREGG DRILLING 01/08/200B 09: 42 9253130302 <br />EHD 29-02-001 <br />6/22t04 <br />San Joaquin County Environmental He th Department Unit IV Well Permit Application Supplement <br />PERMIT SR#: <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 />) <br />or. bP_ery3 beinf Tmhn <br />Title ç fV'iacJ&( <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I hove 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. <br />)C 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 number's are: <br />Carrier: ,cea <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 if 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 />/ /05 Signature: <br />Printed Name: CY riStorft.e/v- 1441-e-r- <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 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 />AUT r T1003 R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-,57 licensed authorized representative), <br />hereby authorize (print name) LEO", 64-#4,1,/blotT COrVE-S7C6.4 120iVe0-5 ‘t 4550c. <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br />one (1) year and Is tirnited to the work plan dated on the front page of this application. <br />8-29-02 / MI <br />Signature: <br />Printed <br />License #: <br />Date <br />name: CMcl ,ex Pitittief <br />Expiration Date: <br />Expiration Date: <br />JOB ADDRESS: <br />Policy Number: 06 ° "(J2,