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01/18/2008 10:05 FAX IM 004/004 <br /> 82/'18/2809 19:14 20936990 VEW DRILLING • PAGE 02 <br /> San Joaquin County Envkonmental'�HealihyDepaltm unit IV VMI Penult APpilcaflolt SUDplemental <br /> JOB ADDRESS; I l II k PERMET SR# 5-(- <br /> Cr <br /> -(- <br /> Cr <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby at M that I am licensed under the provlaions of Chapter 9(COmnlen*9 with Section 7000)of <br /> Division2 of the Businsft end Professlons Code end MY 11CO yg Is In fullforce and e <br /> t kenBe fit ��y C O E Date: <br /> Data: ( O Cont actof Lt� r► <br /> Signature: Title: �—�- <br /> PriM Name: ► <br /> WORKER'S COMPENSA hAN DECLARATION <br /> 1 hereby affirm under Penatty Of Padury one of the following deciaratlons: (Check one) <br /> 111SManQ1wlll maintain s c ertifleate of consent to"If4rtsurs for workers co npensation, as <br /> Provided for by section 3700 of the labor Code, for the <br /> 136"t is Issued. Performantx of the work for which this <br /> I have and will maintain wofkers'cornpensation Insurance, as required by Section 3700 of the <br /> Labor Code,for ttm perronTnance of Ulu work for which this permit is issued. <br /> con�P��n insurance came and ►+1Y workers' <br /> �`1fyUY, TLU,.I"_1 policy numbers are, <br /> Carrlar: Policy Number <br /> I certify-lhatrn the perfortrranee of the work for which this pom*is issued, I shall not employ any <br /> person ki.any manner se as to become subject to the workers'cornpensallon law of Celi(omia, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> LaborrJrC <br /> forffw th conw4y with those pro ns. <br /> Exp, Date: Signature: <br /> Print Name; <br /> tlWAAM Me;PAIL M TValk9fklf NR'+Ri(�'OOMPR OAT10N cONitAde u U UL:AND MALL <br /> k PDULtIia Ato CAM:FDM9 UP Td"MON,a1 ADOMOM To TM coo OF TpK W EREST,TO <br /> A7 rORNEY%MEM AND DAWA6ESAS PROYMM FOR IN 9ECTM 5706 OF THE LABOR CODE- <br /> f R OTHER THAN C-57 SIGNING PEftMT APPLICATION <br /> (signatum of Cbl licensed a <br /> uthorfze d fEpresenlaDYe?, <br /> hereby auttrorize(print nanre) >7CVn� C�iPs/Y� <br /> sign this San Joaquin countywto <br /> a+I Permit on my behalf, I understand this authorimtlon Is valid <br /> for one year area b rxM8d to the work plan dated on the front page of this appllw darL <br /> weeana <br /> Erea� ru►vr <br /> vwuvrw AW <br />