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i1/08/2000 WED 15:42 FAX 916 777 4101 V W DRILLING INC 16002 <br /> 11 X07/`��^3nr <br /> !I;:oc_ �muF r �r L �yi once 02/ A2 <br /> NtiiR7f7RRR R'a•d`J s z�-ru 1:LuuR MACC Iry <br /> San Joaquiin C <br /> _ . ^' i'�iririi i�Girl°i��-�r',.�r�1CAR�on�tlrh�P.itlQrt�.._._. ��----------• <br /> ounty.. Environmal"i,a •p <br /> rtrcnni—► <br /> JOB ADDRESSL'Y lit 'ter W`� ter` ` <br /> _ y <br /> U VA <br /> LICENSSO CONTRACTORS DECLARATION (LCD) <br /> I hereby af'frm that I am licensed under the provisions vi Chapter 9 (commenaing with Section 7000)of Divlsi4n <br /> 3 of the Busind65 and professions Code and my license is In full force and effect- <br /> '/+�^i ZxpirBtion Data: <br /> Co tractor. <br /> DatD. <br /> Signature; <br /> r- \ I <br /> 1�111ALLJ 11pL.,Y\ !FI <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perlury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I fiaVE and will maintain ear Code,p�rjlftcste of consent to <br /> the performance anjurttseworworkers' <br /> to wfi'�T 4rornpe`rarmi� iaarpedvidrd for DY <br /> /Section 3700 of i <br /> �J,I have and will Maintain workers' campensatlon insurance, as required by Section 3700 of the Labor Code, <br /> for the p' <br /> arforrnance of the work for which this permit is issued, My workers' compensation insurance <br /> carrier and policy numbers are: �lr� <br /> /I ,Policy Number: r .�',j;f) <br /> CpTriDr. t <br /> I ueMfy that in the porformance of the work far wnicn noes perri ill 1,3 laoued, 1 analt not amNrly slay 11A,eau/,in <br /> any manner so as to become subject to the workers'compensation laws Df CaliforNa,and Wee that if i <br /> 0n provlsior�s cf Sectian 3700 of the Labor Coda, I ahall <br /> should became subject to the Workers compEnsal <br /> forhwith comply with those pravl6lons. <br /> L.r ),^ 8i®nature: �; <br /> Dale' ) <br /> Printed Name: <br /> WARNING?Fp it 11R.G Tn RtrcUFtL WORD-FtV COMPENSATION COVER. IS UNLAWFUL,AND"Q =P TH -nL I ARS <br /> Sl1BJECT <br /> AN ENIPLOYeRTO CRIMINAL PENALTIES ANb GIVIi.FINES UINTEREST,ATTaRNEY'S FF-P-S,AND DAMAG115 AS <br /> PROVIDED FOR N SECTION 370 OP Y EFLABOR CODE.COMPENSATIQNi <br /> (C.67 licarlsed authorized presentativa),hereby <br /> I, <br /> TI, JK <br /> authorize <br /> t�elan tnls Son JvAvuin County Wan permit APPIIMU0111 on my behalf. 1 underotaml this authorization is valid for <br /> 1 ear and is limited to the work Ian dated on tiro front page oT VIEW e+ <br /> one I Y a G,� <br /> 3� <br /> 11/07/2000 TCir 17:31 rTTiRI NU 64501 Z002 <br />