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11/13/2001 13:25 7146326' EAI PAGE 02 <br /> NOV 06 2001 17: 04 GOGG DRILLING ' 92530302 P. 2 <br /> 11/06I2S91 13:09 7146326754 EAI PAGE 07 <br /> San Joaquin County Environmental Health Services Unit IY Well Permik Application supplement <br /> JOB ADDRESS: (F?;jr,,r'F;A g-7s•4 PERMIT SRO., 60 0 <br /> S*L-� <br /> LICENSED CONTRACTORS DECLARATION (LQ) <br /> I hereby affirm that I am licensed under the provisions 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#: Expiration Date:Ql124I07' �+ <br /> Contractor: <br /> Signature: ~ Title. <br /> s <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> Ihereby affirm under peralty,of perjury one of the following deelaratiors; (CHECK ALL THAT APPLY) <br /> Xhave and will maintain a cahifimte of consent to self-Insure for workers'compensal as provided for by <br /> Secction 3700 of the Labor Code,for tha performance of the work for which this permit is issued. <br /> XI have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> V the performance of the work for which chis permit Is issued. My workars'compertsallorl irsurenee <br /> carrier and policy numbers are: <br /> Carrier: oe!2&ct 4 r is Policy Number: 1Vei—?1 j02 .Cr.0 _ <br /> I certify that in the performance of the work for which this permit is issued, I Shell 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 sUb)va to the workers'ccmponsation provisions of SCctivn 3700 of the Labor Code, 1 shall <br /> forthwith comply with those previsions. <br /> Date• l1�7/O/ Signature: , <br /> Printed Name: ci /rues er <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE H UNDRED THOUSAND DOLLARS <br /> {¢1DOJ10D,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED POOR IN SECTION 37DS OF THE LABOR CODE. <br /> (signature&C-97 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Applleation an my behalf I undersand this authorization is valid for <br /> one(1)year apd to llmltod to the work plan"tad on the front page of this application. <br /> 6.11-2000 f MI <br />