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DEC 07 2001 15: 14 GREGG DRILLING 9253130302 p. 2 <br /> Serit By: Tbxichem Management SysteInC;650 551 0116; Dec-7.01 �PM; Page 2/2 <br /> 12/05/2061 18:48 2094EB3433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health Services, Unit IV Wall permit Application Supplement <br /> JOB ADDRESS: 3515 Ai Pi PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION ILCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7oDo)of Division <br /> 3 of the Business and Professions Code and my license if in full torte and/effect. r <br /> License NLS W-- � .,,r Expiration Date: of-I`31O 3 <br /> vele: 11-7-0L.- Gtr� <br /> or: eM Dt 1l(int *J <br /> Signature: Title: OIC <br /> printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm Under penalty Of perjury one Of the following de0eratlon8t (CHECK ALL THAT APPLY) <br /> hawe and will maintain a conlficate of consent to self-Insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit to issued. <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for Die performance of the work(or which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Csrrier:/2&r& Par,42p 1 Polley Number: <br /> _I cenify 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 U 1 <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 /> Date: signature; <br /> signature: <br /> t <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WDRKERS'COMPENSATION COVERAGE IB 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 37008 OFF nTHE LABOR CODE <br /> 1, (siianature oIC-•5Tlicen■ed authorized representative), <br /> hereby authoriae(print mmol RISS �nI-'AC Q- TOYiCW. Iq t 5 S&.ea AiNC . <br /> to clan this San Joaquin County Well Permit Application on my behalf. 1 understand thls authorization is valid for <br /> one(t)year and is limited to the work plan dated on the front Past of this mppuoatibn. <br /> 6-17-20001 MI <br />