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s <br /> EHD 29-01 07/20/10 WELL PERMIT APP <br /> i <br /> San Joaquin County Environmental Health Department <br /> WELL 8c BORING PERMIT APPLICATION SUPPLEMENTAL <br /> t <br /> t <br /> JOB ADDRESS: 800 W.Church Street,Stockton,CA 95203 PERMIT SR# <br /> F <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> I Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: C-57485-165 Exp Date: / jL//�,c <br /> � <br /> Date: Z / -7 � Contractor: Gree Drilling <br /> E � <br /> Signature: =.� Title: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 4 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> } Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> ! Carrier,A��GP" Policy Number: /5Z/11'1-UU 0/G > <br /> 41101 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> i <br /> Exp. Date: b�.S/�/ Signature: <br /> Print Name: <br /> i -- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ORI ION FOR OTHER"THAN-C-57 SIGNING PERMIT APPLICATION <br /> _(s,Ignature,ofC,-57hcensed_authorized,representative),,_._._,_ <br /> .. _... <br /> --------_. _hereby authorize(print name) ,._to_,. __ <br /> ------------- - -.___..-_._... ----....... ............. ----.............................................-.........._.....-:-- -------------------.._...-.---------------_._....._........._...._..--...................... __._....... - ............... -._........, - --._._._. <br /> _ sign this San Joaquin County- Kell..&-Boring.Eermit-Appiicati-on-on.my behalf„ Lundetatand_thi-s_authorization <br /> . . .... ........ ... ..._.... <br /> is valid for one year and is limited to the work pian dated on the front page of this application. <br /> ...._. <br /> "EHD 2301 07/20/10 " " WELLPERMITAPP <br />