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4-12-205 8-33AM FRDWSCHDRILLING 2097723571 • P. 2 <br /> San Joaquin County Environmental Health:Department fnit IV We11 Perrrttt Application Supplement <br /> JOB ADDRESS: 190,4 W • Oha(-kr' VJ4J , SbCICf'O PERMIT',SRX:-- <br /> LICENSED <br /> RX: -LICENSED CONTRACTORS:.DECLARATION .LF GD) <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 infull force and-effect. <br /> License#: a tGS Expirat+on Dater: S� <br /> Date: 41-/a-05 Contra r: ✓�Cd I t7a�lfw/!� <br /> Signature 9 �^ Tide !}u) <br /> Printed named <br /> WORKERS'COM2ENSATIpU1 ClEGLARAT1ON <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"Labor Code,.for the performance.ofthe Work for..which this permit is issued. <br /> — 1 have and will maintain workers compensation insurance,as,required.by Section 3700 of the Labor Code, i <br /> for the performance of the work for which this pe". it is.issued: My workers'compensation insurance <br /> carrier and policy numbers are: pp _ <br /> Carrier; ,, I -�L --7- � Numher: <br /> 7T�7r e�--FfL7. ? �G�.,Ppli4Y,. ..,, <br /> ' I certify that in the performance of the work for which this,,permit is issued, I shall notemploy any person in <br /> any manner so as to become subject to the.workers'.comparisatiop 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 comply with those provisions. <br /> I <br /> Expiration Date: Signature: <br /> Printed Name: ✓C �i�u� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIESAND.GIVIL FINES <br /> ,UP T6ONEHUNORED THOUSAND DOLLARS <br /> ($100;000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES',AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COOL' <br /> AUTHORJZATI FOR OTHER THAN .0-57 SIGNING PERMIT.APPLICATION <br /> signature.ofC57licensed authorized.,repmsierit ve), <br /> hereby authorize(print name) �`�`'TT�• I`i-tt"1IUIJ <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 /> i <br /> i 8-29.02 r MI <br /> EHD 2942.00 P <br /> n172I04 <br />