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10/02/01 TUE 10:99 FAX 1 9161 0430 SECOR-SACRAMENTO 2002 <br /> Sent 9y: Gregg Drilling & Testing, c. ; 925 313 0302; Oct-2-016:22; Page 2/2 <br /> A WAV VV1 U4,v .( - <br /> Itb OOY <br /> San Joaquin C Zty�nVIMA G _5Mental Health SerVlces,Unit IV Well Permit Applica ooI�SlfpaltNmv <br /> JOB AWRESS: .Saltie 66®PERMIT SR#f- 0021776TToo0 <br /> Z3 002,7--& !/ <br /> LICENSED CONTRACTORS DECLARATION (UD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Susinnse and Professions Cotte end my beans@ is In full inree and effect_ <br /> Unense fr Cis 7 '+ gT16_r— Expiration Date; O/14'ela L <br /> Date: /gv Cordractor, r ' ` raickr <br /> Signature: ! 7iltle <br /> Printed name; <br /> Air <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aftlrm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> XI have and will maintain a eertifinate of consent to self-insure for workers'compensation, as provided for by <br /> sectlon 3700 of the Labor Code, for the peflormenae of the work for which this permit ie Issued. <br /> I have and will maintain warkera'componention Insurance, as required by Section 3700 of the Labor Cada, <br /> it Tor the performance of life work for which this permit Ill issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier/ Ck CIZYl _ Polley Number: <br /> I certify that in the performance of the work fur which this permit is Issued, I shell not employ any Penson 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'cornpensatton provisions of Section 37700 of the Labor Code, I shall <br /> forthwith comply with those provlsiors. <br /> Date:"12 /C?/ signature: Q&Ak s— ffitP t -- <br /> Printed Name: t` dr 0eAG/^ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE LS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CrVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.N IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> pROYIDEG FOR IN SECTION 3706 or THE LABOR CODE_ <br /> eO r (signature o1C.37 licensed authorised reprovenrM ), <br /> lVe <br /> herebyauthatize(pNMname)IQ canew— Ff ��th+er(en 2 <br /> to sign this Sari Joaquin County Wall Permit Application on my beh■H. I understand this outhadmillon is valid ter <br /> one(1)year and Is limped to the work plan dated on the front page of this spplieat= <br /> �1T•217a0/MI <br /> I <br />