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f <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <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#: U� Expiration Date: <br /> Date: ® COnt r: Gregg Drilling <br /> Signature: lam— Title: <br /> t <br /> Printed name: Chris Pruner I <br /> I <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> E <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. j <br /> i <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, i <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: S��'1`T�` Policy Number: ��I DQ_(,I _ 1 <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 /> Expiration Date: q I t I X Signature: <br /> Printed Name: CIA6(�q�}�� <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 /> AUTHORIZATION HER T N C-57 SIGNING PERMIT APPLICATION <br /> I, Chris Pruner (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) Daniel Villanueva <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 /> 8-29-021 MI --� <br /> EHD 29-02-001 <br /> 6/22104 <br />