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11/13/2001 13: 25 7146326"1 <br /> EAI PAGE 03 <br /> NOV 06 2001 17: 05 t,1!_GG DRILLING 920302 P. 1 <br /> 11/86/2001 13:00 7146326754 EAI PAGE 08 <br /> San Joaquin Coanry EnvirOnmanial Health Services, Unit IV Well Permit Application Supplement <br /> 97 <br /> JOB ADDRESS;_©Q ia^ 6r:, aeup PERMIT SR#IL? <br /> I LICENSED CONTRACTORS DECLARATION (LSD} <br /> I hereby affirm that I am licensed under the Provlaions 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 /> License 0: Gd"7 Ezplra6"Date: 01 /D 3 <br /> r f V <br /> Dale: <br /> Contractor <br /> Signature: Title: <br /> Printed name; <br /> j WORKERS' COMPENSATION DECLARATION <br /> i I hereby affirm under penalty of perjury one ofthe idllovr:ng declarations: (CHECK ALL THAT APPLY) <br /> _1( have and will maintain a co[il'Icste of consent to seMinsure 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 /> I have and will maintain workers'compensator)insurance,as required by Seclmri 3700 of the Labor Code, <br /> far the performance of the work for which this permit is issued. My workers' campensetion insurance <br /> Carrieranrdd policy numbetsg�are: <br /> Carrier l.7fi -Z it U"drlipr Policy Number; W4L1r-r.L 42_ <br /> —I certiry that In the perrchrnanca 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'compensatioh laws of California, and agree Wal if I <br /> Should become subject to the we rkers'Compensation pro0sl0ne of Section 3700 of the Labor Code, I shah <br /> forthwith comply with those provisions, <br /> Date; / /! 7/P/ Signature ZA&VE <br /> Printed Name:. E'r' &Ogw— <br /> ir <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVI<RAGE Is UNLAWFUL,AND 3NALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNOREO THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OE COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 37x6 OF THE LABOR COUE. <br /> 1. r�7► 7EJ' �l'(�f/)�/"' (signature ofC-87 liamited authorized reprsOtll2tfveb I <br /> heteby authorize(print namal _ <br /> to sign this San Joaquin County Well Perm R Applioaltan on my behalf. 1 understand thio authorization is valid for <br /> one ttl year and is limited tc the work plan datad en the front papa or thla apps; ati*n. <br /> 8.17.2800 1 MI <br />