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NOV 05 2001 11 : 51 GREGG DRILLING 53130302 p • 2 <br /> 209�11H <br /> AGE STOCKTON PAGE 02/02 <br /> 11/05/2001 11:19 <br /> San Joaquin County Environmental Health 341viC215, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS. PERMIT SR#: <br /> LICENSER CONTRACTORS DECLARATION L( CDl <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. <br /> Llcanse#: � � '"t�1-7 Expiration Date. � �;3l�}I-,02, <br /> Bate: 1 ) Contractor Y �((��� ✓1n <br /> Signature: Tule: 0 r 1 &L <br /> Printed name: fy)T Q ��Li e, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations' (CHECK ALL THAT APPLY) <br /> _I have and will maintain a c'elficate of consent to aNf-insure for workers' compermal on,as provided for.by <br /> Section 3700 of the Labor Code,for the performance of the work for whirls 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 permit is issued. My workers' compensation insurance <br /> carrier and <br /> �policy numbers are: <br /> 1 <br /> Carrier._) 1 4 �L' � u a.4--�L Policy Number: � y C �f� ( <br /> '0 � u <br /> I certify that in the performance of the work for which this permit is Issued, I shall not employ any Pelson in <br /> any manner so as to become subject to the workers'co npensation laws of Ca+ifomla,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cade,I shall <br /> forthwith comply with those provisions. <br /> Dab: Signature: <br /> Printed Name: <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 /> PROVIDEDIN ADDITION TO OR IN SECTION, HE COSTOF OFF THE LAB E.PENSAON,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> l � LL ([� ��t (C,-57 licensed authorised represeruaftel.hereby <br /> .n <br /> i ! f✓v Q. d4 1Ia;rice <br /> to Sign this San Joaquin Courdy Well Permit Application on my behalf. I understand this authofizetw is valid for <br /> one(1)year and is 0mlted to the work Pian dalad on thin frost page of this application. ' <br /> 5-17-20be I MI <br />