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05/26/2005 16 09 9253130302 GREGG DRILLING PAGE 03 <br /> } MPY-26-2005 15;37 P 03/03 <br /> • San icaquin County Environmental Wealth Department Unit 1V Well Permit Application Suppternent <br /> ,JOB ADDRESS:.2 g%S1PERMIT SR#:, <br /> LICENSED CONTRACTORS DECLARATION 0=0) <br /> I hereby affirm that I am licensed under tho provisions of Chapter 8 (commencing with Section 7000) of Division <br /> 3 of the Bualness and Professlans Code and m iloense is in full force and effect <br /> 1- ' <br /> Ucense#, l F,xpiration Date, — 3 <br /> Data, D Coftartor reaqV-J ! I <br /> signature. Title" <br /> Printed name. t✓A r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of the following declarations. (CHECK ONE) <br /> _I have and MI 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 /> XI have and will maintain workers'compenafton insurance, at 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: L Palley Number �D � (a� <br /> I certify 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 Calrfornra, and agree that if I <br /> should become subject to the workers'compensatlan provisions of Sectra 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Expiration Date01�2�ignatur . <br /> Printed Name (-- h + ,y- P X L YAP lam. - - <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE M UNLAWFUL,AND SHALL allBJECT <br /> AN EMPLOYER TO CRIMINAL.PENAL.T199 AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (4100,000),IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTGRN£lr'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> TI FOR OWilER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, {signature ofC-G713eerised authorized representative), <br /> hereby authorize{print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> cne(1)year and is limited to the work plan dated an the front page of this applleatron <br /> 13.49-02 J Mt <br /> i:RD 25-02401 <br /> 8l22/0� <br /> TOTAL P 03 <br />