Laserfiche WebLink
05;18/2005 10: 38 92531303 GREGG DRILLING PAGE 02 <br /> ...., au.a:. ran uollua SEGO$ • <br /> �002 <br /> San Joaquin County Environmental Health Department Unit IV well Permit Application 6upplement <br /> JOB ADDRESS: 5-." c l e T o 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 JCoda and my license is;n full force and effect_ <br /> License#; 57 b /(o� Expiration Date:.. — � / — <br /> Date: �— g— Cont r` � �YI�ILy� TQSfJI`l <br /> Signature; Tltle: {7Lh,� m/t 1Cl�er <br /> Printed name: S+V <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ore of the following declarations; (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workere'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 hove and will malntain 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 olicy numbers are: /f <br /> Carrier: '. Pollcy Number_ <br /> I certify that in the perrormance of the work for which this permit Is issued, I shall not employ any person In <br /> any manner so as to became subject to the workers'compensation laws of California,and agree that if <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith com;J:ith those provisions. <br /> Expiration Date: S Signature: Z � <br /> Printed Name:_� �)Si�/� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (6100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTERESTT ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> QU ZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, - (signature ofC.67licensed euthort¢ed repramentati!vel, <br /> hemby authorize(print name) <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 limited to the work plan dated on the front page of this appllration. <br /> 8-29-02 f MI <br /> EHD 29.02.001 <br /> Nr 4 <br /> J <br />