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DEC 11 2001 13 : 06 GRF ' G DRILLING 929130302 P . 5 <br /> 12 / 11 /01 TUE 11 : 38 FAX 1 918 86 J430 SECOR-SACRAMENTO 12005 <br /> �kSA <br /> San Joaquin County Environmental Health Services, Unit IV Wolf Permit Application Supplement <br /> JOB AWRESS:E]6rnl1`411 in p i P _ _ PERMIT SRk: <br /> -"Ck t (JA <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 1000) of Division <br /> 3 of the Business and Prolessions Code and my license Is in full force and effect. <br /> License C. I Expiration Date: <br /> Date: l l ( IQ / Contractor: l <br /> Signature: Title: <br /> Printed name: <br /> WOKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self4risure for workers' compensation , as provided for by <br /> S etlon 3700 at the Labor Code, for the performance of the work for which this permit is issued. <br /> t< 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 /> n / r �(�215"i$ (o S7ad <br /> Carrier: / - �' Policy Number: <br /> certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in <br /> any manner se 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 these provisions. <br /> Date: 61L. Signature.• <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (s100,0D0.), 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 /> I (signature o1C•57licensed authorized representat1011 A/Zff�v A" k7 <br /> ), <br /> hereby suthorhofpri ! name / <br /> to sign this San Joaquin county Well Permit Application on my behalf. I understand th authorizstlon Is valid for <br /> one (1 ) year and is limited to the work pian dated on the fYant page of this application . <br /> S•17-200D / Nil <br />