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t2001 13:25 7146326754 EAT <br />NOV 06 2001 17:05 GREGG DRILLING <br />/0V2001. 13:00 714632G754 EAI <br />PAGE n3 <br />9253 1 3 0 3 0 2 <br /> p 1 <br />PAGE 08 <br />San Joaquin County EnVironmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADIDRESS: PERMIT SRIP ZO; <br />LICENSED CONTRACTORS DECLARATION (Lco) <br />I hereby affirm that I am licensed Linder the provisions of Chapter 9 {oornmencing with Section 7000) of Division <br />3 Df the Business ard Professions Coda and my license Is in full force and effect. <br />License* C,7 yg.s-zoes-- Expiration Date: <br />Date: / L ir / • Contractor _Gifeyer Cg bef :"Nr,deo 4t. jicele <br />Signature: <br />Printed name firitt er___Feme-P-1-- <br />WORKERS' COMPENSATION DECLARATION <br />! hereby affirm under penalty of perjury one of the followino declarations: (CHECK ALL THAT APPLY) <br />/C. I have and will melnteln a certificate of consRnt to selfLinsure tor workers' compenSaton, as provided for by <br />Section 3700 of the Labor Code, for the performance of the Woric for which this permit Is Issued. <br />)( I have and will rnaintein workers' compensation inSurance, a-s 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 /> <br />Carrier: tethd t nivier Policy Number: We-- •atr-C1C3 C-1-174.C2 <br />I certify that in the performance of the work for which this permit is Issued, I shall rot employ any person In <br />any manner so as to become subject to the workers' cornpehsation laws of California, and agree thal if 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 />Mg; / 1/ 7/rt Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVRRAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE WAN MED THOUSAND DOLLARS <br />($100,000.). IN ADDITION TO THE COST OF COMPENSATION, INTEREsT, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 37us OF THE LABOR CODE. <br />Ciaer:r4ohAt-- 0164,2e ,-' <br /> <br />(signature ofC-57 licoised authorIzed representative), <br /> <br />hereby authorize (print name) <br /> <br />to sign this sari Joaquin County Well Perm!' Application on my behstr understand this authorization is valid for <br />one (1) year and is limited to the work plan ctatact on the front pago of this apolleotion. <br />5.17.2LICIO / MI <br />Zi2 f?..C.'f.. • -