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ISEP_24_ 20071_7 51AM 9253PARSONS-925-979-977 GREGG DRILLING <br />SEP. 20.2007 12.14PM *SONS -925-979-9781 <br />San <br />NO. 6176-'P. 3 <br />raUt 02 <br />NO, 6168 P. 2 <br />— —11.r r-n.irunrnenrai rmeann Department Unit Iv Well Permit Application Supplement <br />JOB ADDRESS: ( PERMIT SRS: <br />q . <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the Previsions Of Chapter 9 (Commencing with Section 7000) of Division <br />3 of the Bu®Iness and Professlons Code and my license is in full force and effeCt, <br />Licensee <br />Date: `�r <br />Signature: <br />Printed na <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm underpenalty of perjury one of the following declarations. (CHECK ONE) <br />I have and will maintain a certificate of consent to aQlMnStIre for workers' Cornpensatlon, ea provldad ror <br />by Section 37'00 of the tabor Code, for the performance of the work for which this permit is issued. <br />I 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 parrnit is Issued. My workers' compensation insurance <br />oarrlerand policy numbers are: <br />�./ Q <br />Gerlier r/ I _ Policy Number: 2A61() 2(Q I <br />I cartify thdt in the pe&rmance of the work for which this permit is issued, I shall not employ any person in <br />any manner aA as to become srbject to the workere' compermation laws of Califomia, and sgree that it 1 <br />should become subject to the workers' compensation prrmiW SAaion 3 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date. 6211 Signature; <br />Printed Name,• Y/ <br />WARNING: FAILURE TO SECUAM WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(8100,000.), IN ADDITION Tb THE COST OF COMPENSATION, INTEREST, ATTORNFrs PI3E8, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 7700 OF THE LABOR CODE*. <br />TIO R OTHER THAN C.$7 SIGNING PERMIT APPLICATION <br />(signature oIC-87licenaed authorlmd representative), <br />lerody authorize (print name) <br />D sign thin San Joaquin County Well Permit Application on my behalf: I underatalld this aufttorindon Is valld for <br />ins (1) yser and le IIrnRGd to the work plan dgted on the front page of tis appllaitlon, <br />EHD 19.02.001 <br />6=04 <br />