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K <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: /�0;5 �� PERMIT SR#: 00 32-00 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions 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 #: 4 8 51 6 <br />Expiration Date: <br />1/04 <br />Date: 11 /22/02 Co ctor: GREGG DRILLING & TESTING, INC. <br />Signature: <br />Printed name: <br />Christopher Pruner <br />Title: Operations Manager <br />WORKERS' COMPENSATION DECLARATION <br />I 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 this permit is issued. <br />x 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: GSM Insurance Services Policy Number: <br />043308245 <br />I certify 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 3700 of the Labor Code, 1 shall <br />forthwith comply with those provisions. <br />Date: 1 1/22/02 Signature:�07,� C <br />92;94,-�Fw <br />Printed Name: Christopher Pruner <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />I, Christopher Pruner (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) -- e—JL —00 Us <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17-20001 MI <br />