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San Joaquin County EnvironmenUil Heatth Services, Unit IV Well Perna Appligtgy 25 <br />2.. 4? -5,„1 1.,_ 1 ,._. 4.2 _I <br />JOB A0bRESS: 2 34% 7 ..-1.00 f'd Oa Avcra-r PERMIT SR*: 1002-7609 <br /> <br />Rfotwinfisk 90 2'7 -(D 1/ <br />LICENSED CONTRACTORS DECLARATION (LCD) <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 Code and my !lemma is in full force and effect <br />License fk, 7 lierregc- <br />contractur.6nags aVi,;te Date: /0/4/0 <br />Signature: Tilie922EAStme:Prrg~egy- <br />ExPlration Date- _121_43/1(22_____ <br />Printed name: <br /> <br />WORKERS' COMPENSATION DECLARATION <br />! hereby affirm under penalty of perjury one ot the following declarations: (CHECK ALL THAT APPLY) <br />I X halre and will maintain a certificate of consent to self-insure for workers cornpensation, as provided for by <br />Section 3700 of the Labor Code, tor the performance of the Work for which this permit is Issued- <br />I have and We maintain workers' companse.tion Insurance, as required by Section 3700 of the Labor Coda, <br />Tor the peffbrmance of the work for which thig permit Is issued. My workers' compensation insurance <br />cian'r and policy numbers ate: <br />Cerrier"PC Cfitflir.e Polley Number: LAM- airkvare0 <br />I certify that In the performance of the work for which this permit is Issued, I shall rot 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 />Data: „td/Zier±e__ Signature: <br />Printed Narne: <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 />(5100,000,), IN ADDITION TO THE cOS7 OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.. <br />• <br />I, 1, 41Pdr (signature etC47 lloensod authorised repreeentativa), <br />harsbyeuthorize (print flame) &fib/ Carges.e /14-P ; Q— <br />M sign this Son Joaquin County Wall Permit Application on my Imshetl, I unclarstand this authorization is valid tot <br />one (1) year and It limited to the work plan dead on the front page of this application. <br />5-1/42Q00 / MI <br /> <br />„ amo0:39 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />Sent By: Gregg Drilling & Testing, Inc.; 925 313 0302; Oct-2-01 10:22; <br />- V VUJ. 1.1.1JV Ntcum-SACRAMENTO <br />F2 002 <br />Page 2/2 <br />Z002