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'RPR 17 2002 2: 49PM GREGG DRILLING 9253130302 P. 1 <br /> ~Fr .i 2002 10 34aM CONDOR EARTH ?ECHNOLOGIES <br /> San Joaquin County Envlronmental„J�gla th Sevic•�,Unit IV Well Permit A n Supplement <br /> F"l A(L l,Jork5 1 1- r o } W Ck Q <br /> JOB ADDRESS:tri^4ya,,Ae J, t"araa -ir ALA-0 CA 5 . PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION L <br /> LD) <br /> I hereby affirm that i em licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: S—Zi `> 0 :Z Expiration Data._ X0,/3!/D 2 , <br /> Date: 4h—/%102 - Contractor: o SCI GJ �� �j/fZA— <br /> Signature: Title: i e—t �r— <br /> Printed name: {_. /Y <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ore of the following declaratlons: (CHECK ALL THAT APPLY) <br /> ave and wAl maintain a certificate of consent to self-Mure for workers'compensation, as provided for by <br /> Section 370C of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and w ll maintain workers'compensation insurance, as required by Sectlon 3700 of the Labor Cade, <br /> for the performance of the work for wh cn this permit is issued. workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: QlYI , rl5, rt AC. f ,-Y Policy Number: <br /> _I certify that in the performance of the work for which this permit is Issued, i 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 1 <br /> should become subject to the workers'compensaQiQnProvisIons of Sect' n 3 86,`f the Labor Code, I shail <br /> forthwith comply with those provisions_ <br /> Date: 41 i y L7.1 Signature: J - <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 /> (S1DO,ODO.),IN Ab4ITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED TOR IN SECTION 3706 OF THE LtQOR CODE. <br /> (C-57 licensed mutt orizad representative),hereby <br /> authorise <br /> to sign this San Joaquin County Well Permit Application on my behalf. i understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front Pape of this application. <br /> 5-17-70001 Ni <br />