Laserfiche WebLink
it DEC 14 2001 10 : 46 GREGO . DRILLING 9253130302 p . 2 <br /> 12 / 13 /01 TRU 13 : 49 FAX 1 916 961 . 430 SECOR -SACRAMENTO _ 10002 <br /> San Joaquin County Environmental Health Services, <br /> unit IV Wall Permit Application Supplement <br /> PERMIT SRS : <br /> JOB ADDRIESSA 1 c tr <br /> �fr�co� ► � <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that 1 am licensed under the provisions o1 Chapter 9 (commencing With SOcdOn f000) of Division <br /> 3 of the Business and Professions Code and my license. is in full force and efleat. <br /> License ff: �� � Ex iration Date: <br /> Date: 1 O contractor, <br /> Signature: <br /> Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> S atlon 3700will <br /> of the Labor Code, focertificate <br /> rihe pellormanceself-insure <br /> of the work forworkers' <br /> which this permit is issuided for by <br /> hveissued. <br /> v l 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 numbers are: <br /> J / K �^ Palicy Number: A)� a �Co D <br /> Carrier: _ / `� a-- <br /> LsIrcenlfy 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' componsation laws of California, and agree that it 1 <br /> should become subject to the workers' compensatioovisions of Section 3700 of bol Code, 1 shall <br /> n r <br /> forthwith comply with those provisions. / <br /> Date: ��� l U / Signature: <br /> � ��— <br /> Printed Name: <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 /> PROVIDED, IN ADDITION TO FOR N SECTION HE F T OF COMPABOR NSATCODE!ONs INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> �( (signature ofC-57 licensed authorized representative), <br /> herstrysuthorlee (print name) eU <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this euthartration is valid for <br /> one (1 ) year and is Itmited to the walk plan dated on the front page of this application. <br /> NINE <br /> 54741100 If Ml <br /> I'I <br />