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08/04/2008 09: 59 9253130302 CREGG DRILLING PAGE 03 <br /> AUG-Qd-2QQ9 09: 13 AMBP.IA 1707 935 GG49 P.03iO3 <br /> San Joaquin County Environmental Health Department Unit IV/Well Permit Application Supplement <br /> .JOB ADDRESS: 126-7 - CG�-�.b C�( , T" PERMIT SR#: 655 <br /> LICENSED CONTRACTORS DECLARATION (LC13) <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 /> , <br /> License t# �� _ Expiration Dater 1 <br /> Date: tt��G/''--' <br /> Signature. - Title:�)�oXGr ?UNf AA117a� <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 /> I have and will maintain workers'compensation insurance, as required by Section 37DO 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. r <br /> Carrier: J �t�iC�► '��`�` _ Policy Number. 68 <br /> I certify that in the performance of the work for which this permit is issved, I shall riot 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 provi 'on f Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ( Signature: ' <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES LJP TO ONE HUNDRED THOUSAND DOLLARS <br /> (xi 00,o00,), 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 /> RUTH OR OTHER THAN IGNINO PERMIT APPLICATION <br /> I, �slgnature ofC-S7 licen9od authorzed repmsentative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County W; <br /> Permit Application on my behalf. I understand this authorization Is valid for a <br /> one(1)year and is IlmitAd to a work plan dat©d on the front page of th Is application. <br /> 9-29-02 1 MI <br /> E11D 29.02.001 <br /> 6P.1ro4 <br /> TOTRL P.03 <br />