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10/10/2006 16:23 9253130302GREGG DRILLING PAGE 03 <br /> 0 Q1003/0U7 <br /> 10/7.0/2006 11,:35 FAX 760 94006 DUDEK & ASSOCIATES <br /> San Joaquin County Environmental Health Department Unit IV Well Permlt ApPbcation Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Business and ProffeessssionS Code and my license is in full force and effect. <br /> License*: `I I`c' � Expiration Date: --- <br /> /I <br /> Date: Contra r: `� Dill <br /> Title: IX- •-. <br /> Signature <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I4-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 number sare: �O�Oa/ / <br /> Carrier: 1Pe 'Y I a�_�Policy Number:�„ tP <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, <br /> shall <br /> forthwith comW�� <br /> ovisions. <br /> Expiration DateSignature: <br /> PrintedName: T <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 /> PROVIDED FOR IN SECTION 3706 OF THE LABOR ADDITION COMPCODEENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> HORI ION FOR OTHER T C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCr�S7,licensed authorized representative), <br /> hereby auth riz (print name) �by-I <br /> to Sign this San Joaquin County Well Permit Applicatlo) onmy behal 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 /> 8-29-021 MI -- -- -'� <br /> PHI);9.02401 <br /> (i 2:914 <br />