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05/18/2001 FRI 14:13 FAX 916 777 4101 V W DRILLING INC Q002 <br /> `... <br /> San YcWa uln County Envir nmantal Health Services, Unit IV'Well-Permit Application Supplernent <br /> JOB ADDRESS: `rtPERMIT SR#: <br /> Stcoyn I C',' <br /> LICENSED CONTRACTORS DECLARATION (LCI]) <br /> 1 hereby affirm that 1 am licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Susinesss and Professions Code and my license is in full force and effect. <br /> License#: �aDqo '7 _ _Expiration Date: llJ �lrt 7. <br /> Date: contractor: <br /> Printed name: �n <br /> WORKERS' COMPENSATION DECLARATION j <br /> 1 hereby affirm under penalty of perjury 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 /> /3oi[ion 0700 of tho Labor Codc, for th0 porformancv of tho work_for which this. rArmif 1s ipsi iod <br /> 1 V I have and will maintain workers'com pen evtiesn Ingl,tranm, as 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 /> carrior and policy numbers are: WE- <br /> �� / <br /> r- �Z11LiPl' I r(-r9 it-. Pnll"Numh /WE—er: �1! 5-J�Y ri,? <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become silbject to the workers' compensation Jaws of California, and agree that if I <br /> should t)ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <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 THOUSANp DOLLARS <br /> !N ADD)T)ON TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES A3 <br /> PROVIDED FOR IN SECTION 8706 OF THE LABOR CODE. <br /> 1; _ <br /> authorize <br /> W-11 0-14 la valid for <br /> ono jl)dear and Is limited t0 the work plant dated on the front page of this application. _ <br /> I..V"N'1J� IAI"TJ L In I i <br />