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9pr 04 05 12:30p Mitchell Drilling 707-444 9049 p.l <br />San Joaquin County Environmental Health Departinerlt Unit IV Ytlell Permit Aop1,castton Supplcme.nt <br />JOB AnDRESS: 17 \ v �-� �'� °" PERMIT SR#, ' <br />LICENSED CONTRACTORS DECLARATION (L <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Erction 7000) of Divisior <br />3 of the BJsiness and Professions Code and my Peense Is in full Bron and effect <br />License #. y 57 *� 6 7 2 617 Expiration Date: `lam <br />Date: Contractor: ^1+ i T6 H LL L- VP -)"0j(1 f nJ l/, <br />Signature: TIl-: V6/0 5 <- <br />Printed name: <br />WORKERS' COMPENSATION DECLAMATION <br />I hereby affirm under penalty of perjury one of the fotluwing declarations. (CHECK ONE) <br />I have and w81 maintain a certificate of consent to self -insure for workars' cornpens.;ation, as provided for <br />by Sectinn 3700 of the Labor Code, for the perfnnnance of tho work (or which a is permit is issued. <br />21- 1 have and will maintain workers' compensation insurance, as required by Section : 100 of the Laoor Code, <br />for the performance of "te work for which this permil is issued. arty workers' rompensatlon insuranQ-o <br />carder and policy numtters are: <br />Carrier 0 51rLL- (A x i INS . cu Policy Numbor,. o 0 7— o a v Z y! b 7 <br />I certify that in the performance of the work for which this permit is issued, 1 shall ncI employ ?,ny person In <br />arty manner no An to become subject to the workers' compensation laws of Califorra, and agree that I' <br />should become subject to the workers' compensation provisions or Section 3700 of he Labor Cole, i shal I <br />forthwith comply with those provisions. <br />Expiration Date: 1 f 0 (a Signature: <br />Printed Name: P PQJ L- 62 <br />WARNING: FAILURE TO SECURE WORKERS' CONPENBATION COVERAGE 13 UNLAWFUL, AND SHALL SU®JECI <br />AN EMPLOYER TO CRMNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOL13AND DOLLARS <br />(4100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMI7 APPLICATION <br />1, PR, <br />G E -v re G f--- . <br />hereby authartze (print <br />otC•57 <br />, +jV-K- SC5:,C-7 0+j <br />onsod at.ihorizad roprosentativel, <br />-6 E <br />to sign thla San Joaq.iin County Well Pernk Appmratica on my behalf. I understand this authorization In vaild for <br />one (1I year and is limited to the work plan dated on the front page cf fi's application. <br />FrID W-07.001 <br />6712104 <br />