Laserfiche WebLink
i <br /> f ✓ <br /> San Joaquin=DECLARATION <br /> epartment Unit IV Well Permit Application Supplemental <br /> fJOB ADDRESS: ckton PERMIT SR# <br /> LTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: `?- `J/ C� Gj _Exp Date: 1 j <br /> Date: May 2, 2010 Contractor: Gregg Drilling Inc. <br /> Signature: Title: <br /> Print Name: P//�_ <br /> WORKER'S 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 sell-insure for workers' compensation, as <br /> C provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: b Policy Number: <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provision . <br /> Exp. Date; ��'}�(/ Signature: <br /> Print Name: e <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTHORI TIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I• _ (signature of C-57 licensed authorized representative), <br /> hereb aoriz rint name) gtfc a_ to <br /> sign this an Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and Is limited to the work plan dated on th a front page of this application. <br /> EMD Y9-01 WSW <br /> WELL PERMn APP <br />