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02/29/2006 16: 15 925313030 GREGG DRILLING • PAGE 03 <br /> San Joaquin County Environmental Health Department Unit IV wall Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. I <br /> License#: � Expiration Date:_ i '3( D <br /> Date --I <br /> ontra Dnp I l i n ►'J hG <br /> Signature: Ttie: r�,L tlO�tf I l0.Nt(�l1 <br /> Printed name- Y 1S'Cn e; <br /> J <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br /> �gS <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 permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Q V1 <br /> Carrier: vriV 1 Ivt r I I Policy Number: <br /> I certify 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 if I <br /> should become subject to the workers'compensation provision of Section 3700 of the labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: CJ I Signature: <br /> Printed Name: �/Y 11 1 a mil <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 /> (4100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> MHATI FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> I, (signature DIC-67 licensed authorized representative), <br /> hereby authorize(print name) k a a -r c-L- <br /> to <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for , <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-20.02/Ml <br /> Er1D 2s.o2.001 <br /> 6122104 <br />