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06/06/2007 16:18 9253131302 GREGG DRILLING PAGE 02 <br /> E T IC ENGINES a Pi <br /> PA(aE e2 <br /> Sart Joaquin County E <br /> n <br /> vironmental Health Department Unit IV Well Permit Application Supplement i <br /> JOB ADDRESS: 56Fi4'C.1"- JS L- PERMIT SR;#: <br /> Sfi w, CA <br /> LICENSED CONTRACTORS DECLARATION {LCD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Div',sion j <br /> 3 of the business and Professions Code and my license is In full force and effect, <br /> License# g�S .Expiration Date:- <br /> Date: <br /> Date:Date; tracto <br /> aleQ' �70,Si nature: <br /> Printed name; T : 1r <br /> WORKERS' COMPENSATION DE'CLARATiON <br /> i hereby affirm under penalty of perjury one of the following declarations- (CHECK ONE) <br /> I <br /> I have and will maintain a certi€icate of consent to self-insure for workers-co'rpensat;on,as provided for <br /> by 5ec'ion 37170 of the Labor Gode,for the performance of the work for which this hermit is Issued, <br /> I have and will maintain workers' cornoensation insurance,as required by Section 37DO of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carver and policy numbers are: <br /> Carrier: �-P � !�? <br /> Policy Number: <br /> I certify that in the performanoe of the work for which this permit Is issued, I shall not employ ar <br /> any manner so as to become subject to the workers'compensation laws of California, and agree ark f on in <br /> shoUld bAco he subject to the workers'compensatlon provision o'& 0 3706 of the Labor Code, I sh811 <br /> f <br /> forthwith comply with these prov'sions, <br /> Expiration Data: 9! O Signature: - <br /> Printed Nam; -tv <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 /> (5100,OOO.j,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 /> AUTONeF107-NER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCS7 licensed authorized representative), <br /> herby authariz®(print name) gOV4N" <br /> . I <br /> to sign this Ban Joaquin County Weil PArmit Application on my behalf. I understand th s avthbrizatioh i9 valid for <br /> onrs(1)year and i9 limitetl to the work plan dated en th9front pwye of this Applicaflpn. <br /> 8-St9.021 Ml I <br /> I <br /> FHD 24.(32 X01 <br /> 4/22/04 <br />