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02./23/2001 FRI 14:19 FAX 916 777 4101 y 4i' DRILLING INC <br />JAt4lrllqn _ .-- <br />San Joaquin County Environmental klealth Services, Un1t:1V Well.-Pertmit.Aplplicatlan Supplement <br />JOB ADDRESS: �y Il�,�J' �`�� P RMI7 SR#A42 <br />11� V�� LCD <br />LICENSED CONTRACTORS DECLARATION ) <br />2002 <br />I hereby affirm that I am licensed Under the provisions of Chapter g (commencing with Section? 7000) at Division <br />3 of the Business <br />� andrlprofessions Gode and my license Is in full force and effect. <br />License #' fiooq /" � _ __ EXpira:ion Date: _ <br />Date: <br />Signature: <br />Printed name: <br />ntractor.1 1n C <br />'i�4.c�%� ... Title• — <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />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 thlis permit is Issued. <br />/ t <br />Y I 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: �«�n Policy Number: <br />I certify that In the performance of the work for which this permit Is issued, 1 shall not employ any person 1n <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 <br />should become subject to the workers' compensation provisions of Section 3700 of the Labo Code, I shall <br />forthwith cornply with those provisions. <br />Date: <br />Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PE14AL71ES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br />PROVIDED ORCIN SECTION HE COST <br />O T OFLABOR CODE ON INTERE $T, ATTORNEY'S FEES, AND DAMAGES AS <br />lie F7 llcansad authorized r00t040ntatjve). fzereby <br />/../__. <br />authorize <br />to sign this San Joaquin ICounty Well Permit Application o y behalf. I u demtand this authorl Atlon is valid foT <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />'d <br />