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APR 1G 2002 1 : 35PM GREGG DRILLING 9253130302 P• 2 <br /> APR-16-2002 TUE 10' 11 AM A*MiCKE1SON RAN' N0, 91693 0 P. 02 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application supplement <br /> JOB ADDRESS:2SZ✓ !/gyp �o��✓, %r �pERM1T SRa�: 062,26 '0 <br /> LICENSED CONTRACTORS DECLARATION (LCM <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)Of D;vislon <br /> 3 of the Business and Professions Code and my license Is in full force and&fact. <br /> License#:( .,r2 �1��. Expiration Date: 1 ,r0_y <br /> Date:_! kJ to _— Contractor: �f O�if;I <br /> Signature: LL rt 7itle:O�RC17TIdQ�/rfO!►Or[9I' <br /> Printed nawne: setl'/LS.CS04r � nA� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> X1 have and wits maintain 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 /> XI 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 /> Policy Number:�� <br /> _ I Certify that in the performancehe w <br /> of tork forwhich issued, I shall not employ any person in <br /> w any manner so as to become subject to the workers' compensation laws of California, and agree that N 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 /> Data: �( Q Z,.�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 /> ($J00,000.),IN ADDITION TO HE COFTHE SF COMP CODE INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N SECTION <br /> 1 'J��./fr�' \ ��.\,` (signature otC•57licensed authorized represontauve), <br /> hereby authorise(print name) LJ C�rl�LS <br /> to sign this San Joaquin Courtly Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)ysar and Is limited to the work plan dated on the front page of this appll cation. <br /> 517_2000/MI <br />