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JAN 21 2002 9: 48 GRECq DRILLING 9253130302 p. 2 <br /> -ft . aav uliju SECOR-SACRAMENTO <br /> � tea. [don <br /> San Joaquin County EnvkontnentW Health Seryices,U"II IV Well Permit Application Supplement <br /> JOB ADDRESS: 1- - 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()!vision <br /> 3 of the Business and Professions Code and my license is in full force and effect.. <br /> License#:6-r7 Expiration Datr <br /> Data: / O Contractor: ' <br /> Signature: Title: �12rO� s- �J�►i,,,,a�. <br /> Printed name: (;64 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> t have and will maintain a cerGfioate of consent to self-Insure for workers'Compensation,as provided for by <br /> I y <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> 4rI 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 /> Carrier: ¢ �l�t�/- Polley 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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith cornply with those provisions. <br /> Date.JJ--Z-1 /D--Z- Signature: <br /> Printed Name:_�'..`l/11 � <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 /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODS. <br /> 11_t�ixtori�' ��'un¢f' <br /> (signature ofC-57licensed authorized representative), <br /> hereby suthorizs(print name <br /> to sign this San Joaquin CountVwsu Permit Application On my behalf. I understand this authorization Is valid for ' <br /> one(1)year and is United to the Work plan dated on the front page of this applleadon. <br /> 8-17.2000/MI <br />