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jAmatRou 15:31 FAX 916 777 -1101 y w DRILLING INC <br /> <br />Z002 <br />PERMIT#: <br />t I. NIL 'A 1.4 s . r emr • 1 <br />`7(9096-4/ _ <br />I hereby affirm that I AfAqicEkl*Riatcg0444W1-91511SpI2ErtieNikATAIlgthdectD) 7000 of Division <br />3 oif the Business and Professions Code, and my license is in full force anc effect_ . <br />.1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70001 of Divison <br />LiO§etAie Business and Professions C rj4 Sitgatticmyistrise is in full force and effect. <br />License #: Date <br />Contractor Expiration Date: _ /30/ <br />Date: Ca- P4_ <br /> <br /> ontractor I • 'l -1--r) C - <br />A C)) 1 ERS' COliFFENTSATION ,d5CLA TION <br />AAA_ I 14 Title: -kJ <br />1 i . <br />1 'n WrYgtarr-Nme-:t ., ,ih8 i - cOficait:Ft <br />Insurance, or a certined • , 1,y fIreeo`f <br />WORKERS' COMPENSATION DECLARATION <br />Ex p. Date Company <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />L-3 tertified copy is hereby furnished <br />,oactifieda torsfictvgiktnp4tokneaciiiftp3ofttsnirmidelorifaittgia Aar 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 />V I havrtql1V119-4F . FMPTION FROM WORKERS' COMPENSATION nsuRANc= r, am n r ers' compensation insurance, as required by .5ecrion Jruu or the-Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />(Th's sectign-me4lactOiitcppp1e6046itiqq oermit is tor one hundred dollars (STC)0) or !ess) <br />I c nify that in thz iero ancr th- work for which this permit is issued. I shall rilcit employ any person in any manner so <br />as o Le • ompensatiort Laws of 04iitiVriitumber: IV WC-54-iii:55-6.5 be:a:Mem , ; •t <br />p I certify that In the performance oXitilaiiiionitk for which this permit is issued, 1 shall not empty any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />NOTICE rteirinalBWitigic9W8-}9rZfsWicrbeRIPfstb8jaPRIt@liCoi-144i <br />Compengttg9-arsli12)Xswbf theclabb Itiiiii,lou must forthwith comply with such provisions or this permit shall <br />be deemed revoked. <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 />($100,000.), 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 />JOB ADDRESS: <br />San Joaquin County EnvironMental Health <br />Joe ADDRESS: <br />rvices, Unit IV Well Permit Application Supple.rpent <br />,coz5-0/v <br />PERMIT _SE.#* C0.2, 0/6 <br />ECLARATI <br />signature: <br />t to self-insure, or a certificate of Workers Compensation <br />LattiTel. <br />Da <br />Signaturo: <br />to sign this San Joaquin County Well Permit Application my behalf. i understand this authorization is valid for <br />1 Alio ,1 1 ,_,A, di (C-57 licensed a honzed representative). hercky <br />authorize <br />/ / L <br />\-Q_ \i YC1 IL.• ,4 <br />one (1) e r and taiimitod to the work plan dated on the front page of this application_ <br />411111 <br />E 'd. <br /> le.40>LIA HVVS:C1 665I-V-0