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Oct-27-99 14:50; Page 2/2 Sent By: Gregg Drilling & Testing, Inc.; 925 313 0302; <br />San Joaquin County Environmental Health:Services, Unit IV Well Pooch Application Supplement <br />JOB ADDRESS: z-7c. I 03i754,4 Otra/t .5 hz.c.46-1pERismr sfut: <br />IA - 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 it RS Expiration Date: I <br />z Date: i-41;7/ 3 Contractor. Crer=e) ri I i -resh rivc_ <br />Signature: Tide: Opeirabnia5 <br />Printed name: <br />WORKERS' COMPENSATION COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />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 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 /> <br />•• <br /> <br />Carrier: 60 Policy Number: <br /> <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, I shall <br />forthwith comply with those provisions. <br />Date: /0/7-V "/ 3 Signature: <br />Printed Name: Pf 0-1 e/— <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 V4 OF THE LABOR CODE. <br />tithed= —6t <br />(C-57 licensed authorized representative), hereby <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />Z 'GI <br />one 1 *sr and is ilmIted to the we dated on tha front of this a isstion. <br />PIJ I4VØ IL 66l-9-01