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-41 411 GUUo lu:1L 7LDJldl93Y ;.GREGG DRILLING <br /> � � /t PAGE 02 <br /> e � F <br /> San Joaquin County Environmental Health Department Unit IV Wail Permit Appltoafionn 5 Opt <br /> meet <br /> JOB ADDRESS- 1717 South CenVer Street PERMIT SR#: <br /> " LICENSED CONTRACTORS DECLARATION LCD) <br /> ' I hereby affirm that I am licensed under the provisions of Chapter (commencing with Section 7000)of Division <br /> ' 3 of the Business end Professions Code and my license fs in full force <br /> 'and affe/ctt,, i <br /> License#:_r���J✓� n F�tplratioii Data`:J✓��/ V 4f <br /> i Data: / Co G l .cr�' tai 1��11/ 1 7 �Qdt lr TIL <br /> Slgnafure Title:� <br /> + Printed name: <br /> 11 t <br /> LNORFCJ`R8' CONmPENSATION DrcLARATiON <br /> t I hereby affirm under penalty of pedury one of the following declarations: '(CHECK ONE) <br /> r <br /> I have and will maintain a certificate of consent to solf-insure for workers'compensation,as provided for <br /> by Section 370D of the Labor Code, for the performance of the work for which this parmk is Issued. <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. y workers'compensation insurance <br /> carrier and-policy numbers / t are: /� <br /> CarrierCarrier �{�abaq Policy Number d�aRp I <br /> I certify that in the performance of the work for which thise " u <br /> p rmit is issued,I shalt not empty any person in <br /> any manner so as to become subject to the workers'compensation laws of Califomia,and agree that if t <br /> l <br /> should become subject oo the workers'compensation provisions o 3700 of fire Labor Code, I shall <br /> " forthwith comply <br /> Qw�ith those provisions, <br /> ExplratFon pate: . v ( 06 Signature: �t '^ �'n1 fF <br /> Prirdad Name: C Y I r( & l tJf/f l`C/+ Y(ti—Vier <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 /> ($100,008.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> FOR OTHER THAN C-ST SIGNING PERMIT APPLICATION <br /> AZZAT <br /> ignature ofC•s7 licensed authorized raprasentative),oriza(prlItnamalfS( Pc—/ A�dcrem, a <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand this authorization Jr.valid for <br /> one'(1)year and is limited to the work plan dated on the front page of this app8oatlon. ' <br /> 8-20'ma2 7 At <br /> I <br /> l Ern 29-01A01 <br />