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05/15/2002 15:42 <br />05/15/2002 14:28 <br />7078234258 <br />2094u-,433 <br />WEEKS DRILLING <br />FIFTH FLOUR <br />PAGE 02 <br />PAGE 01 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: <br />T <br />arc y <br />PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATIONLi CD) <br />I hereby affirm that') am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions ode and my license is in full face ana Effect. <br />License #: C,57 -177(P 9 I Expiration bate: q 2— ^ ----- <br />Date: <br />Signature: <br />WIN <br />Printed name: Nn2ld(1 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />V 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 this permit is Issued. <br />_ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Cade, <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�-�c�. fitind,.,-I�Lurniaftlir-y Number: <br />I cert!fy 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 California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 37 0 of the Labor Code, I shall <br />forthwith comply with those provisions. 1 <br />Date: 5 Signature: V <br />Printed Narrip_ DonDldr r <br />WARNING: FAILURE To SECURE.WORKERS' COMPENSATION COVERAGE 19 UNLAWFUL, AND SHALT, SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO GINE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE ST OF COMPENSATION, INTEREST, ATiORNI:Y's FEES, AND DAMAGES A5 <br />PROVIDED FOR IN SECTION 3706 F THE LABOR CODE. <br />l (signature ofC-57 licensed authorized representative), <br />hereby authorize (print <br />I Application on m behalf_ I undersWnd this authorization is valid for <br />to sign this San Joaquin County Well Permit App Y <br />one (1) year and Is limited to the work plan dated on th0 front Pag® Of this application. <br />5-17.20001 MI <br />