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11/07/2007 12: 01 9253130302 GREGG DRILLING PAGE 05 <br /> . NOU-07-2007 11:23 'CRMBRIA 1707 935 6649 P.05/05 <br /> San Joaquin County gnWronmental Ft Ith Department Unit IV Welt Permit Application Supplement <br /> JOB ADDRESS: 1e4- PERMIT SR#: <br /> W?O W . C-�r�O�A.�I.n W+^6 <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that 1 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 end effect. <br /> License#: "� / - `7 b5l U15 Expiration Date: ) 1 ,31100 <br /> Date: rad Y�l 1 k� <br /> Signature., Title: 0"S �G2M�ge1'^ <br /> Printed name: N rt I'lz lli*1, ?rYAme c <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 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 worts for which this permit is issued. <br /> -11(I 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 numbers are: /� <br /> Carrier: V ( Policy Number.�p, 0 <br /> I certify that in the perfiormance of the work for which this permit is issued, I shall not employ arty person in <br /> any manner so as to become subject to the workers'Compenadlon laws of CaAforiia,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: B 0 S Signature: <br /> Printed Name: <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 /> AUTH T ROT THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature ofC-67 licensed authorfred representative), <br /> hereby authorize(print name <br /> to sign this San Joaquin County Well Permit ApplicatJon on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and Is rimmed to the work plan dated on the front page of this apppcatlon. <br /> 8,29-021 Ml <br /> E-M 29-02-007 <br /> 6/22t04 <br /> TOTAL P.05 <br />