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NOV 05 2001 11 : 52 GREGG DRILLING 9253130302 p. 2 <br /> 11/05/2061 11:19 2094671. AGE STOCKT0N PAGE 02/02 <br /> San Joaquin County Environmental Health SerYices, Unit lV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCDj - <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Secfton 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full force and effect. <br /> License#: � hJ� `��� ExplraGon Date: <br /> Date; Contractor 1r � <br /> Signature: ° Title: o�� <br /> Prf ntsd name: <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty of perjury one of the following declarations: (Ct1ECK ALL THAT APPLY) <br /> _I have and will maintain a ceillflcate of consent to se f-insurefor 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 /> 1 have and will maintain workers'Compensation insurance, as required by Section 3700 of the Labor Code, <br /> I for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are. <br /> Carrier,1 [ I I��� /1� Policy Number. C `©Co STO u <br /> I certify that in the performance of the work far 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*_ Signature: <br /> Printed Name:�. <br /> WARMING:FAILURE TO SECURE WORKERS'COANPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNk f'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR 1N SECTION 37/00 OF THE LABOR CODE. <br /> I, iY l C3 y (C-S7 licensed authorized representative),hereby <br /> authottoe y C� n �� i I I at 0' <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 und4rstand this authorizOOM Is valid for <br /> one(7) year and is limited to the work plan dated on the from page of this application. <br /> 5-17-20001 Mt <br />