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10/02/01 TUE 10:30 FAX 1 91 1 0430 SECOR'SACRAME>TO Z002 <br /> Oct•2-0 :22; Page 2!2 <br /> Sent By: Gregg Drilling & Testingv ��y• ;Y� 925 313 0 <br /> 3 <br /> 08i SAfRAYH2rT0 E002 <br /> San,Joaquin C Z yE�on genml Heatth Services,Unit IV Well Permit Applic�afOorL5Vprrlemegt <br /> d00 ADDRESS: � 't `i .Suv,;o l�oc�PERMrr SR#- DOZL�7609U <br /> 2_3 �� 5 Rivwh k <br /> LICENSED CONTRACTORS DECLARATION ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commertoing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. / <br /> Expiration Date: a 113/A 3, <br /> Date: Contramor.6:ii � �1�'t'a <br /> Signature: Title 1'olgAw' <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will malniain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> I have and wl5 maintain workers cornpenaelon insurance, as required by Section 3700 of the Labor Coda, <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����r1��� Polley Number: Nib�l�!!6S 80 <br /> I cenlfy that In the performance of the work for which this permit is Issued,t shall not employ any person in <br /> any manner so as to become subject to the workers compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provie ons of Section 3700 of the Labor Code, I shall <br /> forthwlth comply with itme provisions. <br /> doe <br /> caw: ,�d Signature: <br /> Printed Name: � tonal <br /> WARNING:FAILURE TO SECURE WORKCIl COMPENSATION COVERAGE tS UNLAWFUL,AND SMALL SUBJECT <br /> AN EwLdll TO CRIMINAL PENALTIES AND CrV1L FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (511)0,000.},IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> ppOVIDED FOR IN&1 3706 OF THE LABOR CODE <br /> _ <br /> 1, /- �� (df neturo giCM Imansed authorlsad rePtiaantatirre), <br /> , <br /> tr�rr. �ortye �Ja�f f�� l <br /> hereby authorize(PNM"mall <br /> to sign this San Joaquin COYMY Well PeIr lh APPOmtlon on my bah■Tf, I understand this wuthaftIl on is valid Ter <br /> r and f1)limned to the work len dated on the front page of this spOicaUon. <br /> one(1)year P <br /> `r17.2D00/MI <br />