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e1310112000 FRI 10:21 FAX 916 777 4101 V W DRILLING INC IM 002 <br /> San Joaquin County Envlronsri$ntaii4ealth Services,Unjt4V Well Pen uf-App9catIonSupplement <br /> JOB AIDDRESS: RERNIIT SRS: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that i am licensed Under the provisions of Chapter 9(commencing with Section 7400)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: lr � (�7 Expiration LJjpiir�il rat��111ion Date:_r_�,�OI <br /> Date: ontracWr: \�f)1,�! r . C - -- <br /> Signature' 4 (( Title- _ <br /> Printed name: 4,Jo _ - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedjury one of the following declarations, (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for by <br /> Section 3704 of 1ne labor Code, for the performance of the work for which this permit is issued. <br /> V/I have and will maintain workers'compensation insurance,as required by Section 3700 of tree tabor Cads, <br /> for the performance of the work for which this permit is issued- Illi+/workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Policy Number. <br /> I certify tl'iat 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 sub}ecr to the workers'compensation I*"of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3708 of the Labor Code, I shall <br /> forthwith comply with those provisions- <br /> Date' Slgnatu re- — <br /> Priinted Name! <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EmPLOYER TO CRINH14AL PENALTIES AND CIVIL FIN"UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), !N ADDITION TO THE COST OF COMPENSATION,INT]ERE.Sr ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE TABOR CODE, <br /> I, {C57 licensed authorized a epresentative). hereby <br /> authorize ' <br /> to sign thle San Joaquin County Well Permit Application On My beh*lf. I understand this autha tzation is valid for <br /> one(1)year and li;limited to the worx plan dated on the front eNa of this a IiealYon- <br /> E -d V408-A Wb 1�5=8 L 666 t–ti0-0 l <br />