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qDV 15 2002 3: 15PM GREGG DRILLING 9253130302 P. 2 <br /> Nov 15 02 02: 23p K :zon env. Ino 916 9:�f 172 p, 3 <br /> FJO:BADDRESS:— <br /> Joaquin County Environments!Heajth p dnent Unit IV WeII Permit Application Supplement <br /> S B � t e2 (�3Z i l7 8 <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hefeby affirm that i am licensed under the provislons of Chapter s(commencing with Section 7000)of Division <br /> 3 Of the Business and Professions Code and my license is in full force and effect. <br /> License#: ie r r� �.� t I b 4 <br /> 1 Ex i anon Date:— lyl )�! j <br /> iDate: i i Contrac c <br /> Signature: <br /> Title: <br /> Printed name: ( t1 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty Of perjury one of the following declarations: (C HECK ONE) <br /> _I have and will maintain a certificate of consent to seH-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 /> 1 <br /> dive and will maintain workers'compensation incunnce, ae required by Sectiun 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 po11Cy numbers are: <br /> Carrier: Policy Number. <br /> t certify that in the performance of the work-for which this Permit is issued,I;hay not employ any persun in <br /> any manner so as to become subject to the workers'compensation laws of California.and agree that if I <br /> forthwithshoultl become subject to the workers'comp sabon provisions of Section of the Labor Code,I shall <br /> /comp�lyy with those provisions. <br /> Date: ) ( r 1 S ! a7 SI noture: <br /> printed Name: 471 1/ J �,17J <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 /> 410,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 7706 OF THE LA80R CODE. <br /> AUTHORIZATION FOR TNER THAN C-57 SIGNING PERMIT APPLICATION <br /> I'-- (slgTTure Glc-6711 rnsed authorized representative), <br /> II hereby authorize(p t nam,(e))�/''y <br /> L1.2lesignDdssanJoaquinCo9ty App ca roll on my steal. 1 Understand this authorizatian is valid for <br /> one i1)year and is limited to the work plan dated on the front page of this application. <br /> 5-29-021 MI <br />