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09/17/2010 13: 11 2094697704 V&W DRILLING PAGE 02 <br /> t • <br /> San Joaquin County Environmental Health Department Unit IV Well.permit ,Application Supplemental <br /> JOB ADDRESS: I � ° V�C C` ,`rM NM <br /> 33 � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect n, <br /> License#: th <br /> _ 4a C -( I Oq— _Exg Date: 11 e O� <br /> Date: Contractor: ,A <br /> - 11` YI 1l1 ri� ) r}C 1 <br /> Signature: Title: <br /> Print Name: - V-1 CE' s — <br /> WORKER'S COMPENSAttON DECLARATION <br /> I hereby affinn under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this Permit is issued- My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier; lLCi )G Policy Number: O pf <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I s alliforthwith comply with those provis ns. <br /> Exp. Date: Signature: <br /> Print Name: OL <br /> L��?( L� <br /> WARNING:FAILURE TO SECURE WORKERS•COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL 8— U6JT <br /> CRIECT AN EI�LpyER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO S10e,0M.IN ADDITION To THE COST OF COMPENSATION,INTEREST <br /> ATTORNEY'S FEES,AND DAMAGES A8 PROVIDED FOR IN SECTION 9706 OF THE LABOR COOS. <br /> T O - JI�1 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I• `�' 74� T- <br /> to of C-67 licensed authorized re <br /> presentauve), <br /> Hereby authorize(print name) <br /> to <br /> sign this San Joaquin county Well Permit Application on my behalf, 1 understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 029N?llrl <br /> FlO29pi 115x] <br /> WELLP his A%' <br />