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F15/ 15/ 2002 15 : 42 70782347. 58 WEEKS DRILLING . .-- PAGE 02 <br /> 05/ 15/ 2002 14 : 28 209468a433 FIFTH FLOOR PAGE 01 <br /> FILE COPY <br /> San Joaquin county Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:., PERMIT SR#: <br /> `["racy <br /> LICENSED CONTRACTORS DECLARATIONI(. C1) <br /> I hereby affirm that ) am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Proffe-s7siions Code and my license is in full force and effect. <br /> License #: C5 /_' I ! I l (/ I Expiration bate: qL3(0 0z <br /> Date: 511710 Contract : ly ( i s. r 1. r i QV 1 -( Aril n <br /> Signature: d: [a �IQQP Z A4 An TNRie, 1"I II (1() C�QI� g} <br /> Printed name: noICI L" prQP.c <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of per ury one of the following declarations: (CHECK ALL THAT APPLY) <br /> V I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> section 3700 of the Labor code, for the performance of the 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, <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: Policy Number: jL <br /> I cert'dy 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 37PO of the Labor Code, I shall <br /> forthwith comply with those: provlsions. <br /> pate; 5 5 Signature: <br /> Printed Name: , 'DonD I l 7 rner <br /> WARNING: FAILURE TO SECURE .WORKERS' COMPENSATION cOVERAGE 19 UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 37061F THE LABOR CODE, <br /> (signature ofC-57 liconsed authorized rapresentative), <br /> hereby authorize (print name) e O <br /> n miorr 0 ) <br /> to sign this San Joaquin County Wall Permit Application on my behalf_ I understand this aalhorizatlon is valid for <br /> one (1 ) year and Is limited to the work plan dated on the front page of this appllcatinn. <br /> 5-17.2000 f MI <br />