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G8/2.7/2001 MON 12-35 FAX 916 777 4101 V W DRILLING INC / San Joaquin CountyEnviron ental Health.Services-, Unit IV Well PsrmitApplication Supplement l , C ' JOB;ADDRESS: 2 PERMIT SR#: om CIE V1 -, I e,-)�� LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License#: G' Expiration Date: q/W Date: . Con tactor: Tlti1711 Signature: If V�� ✓" Title: Printed name:%, I - i f. 4_-i' WORKERS' COMPENSATION DECLARATION i I hereby affirm under penalty of perjury one of the following declarations-, (CHECK ALL THAT APPLY) _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. JI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier- &-a Fuji d Policy Number: -713 i _I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith c mply wi those provisions- i Date: Signature: 7 { -� -/� Printed Name WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($900,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDE=D FOR IN SECTION 3706 OF THE LABOR CODE. I L (C-57 Incensed auth�o!rized repres tive), hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(9)Year and Is limited to the work pian dated on the front page of this application. _ ,.