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08/27/2001 BION 12:43 FAX 918 77-7. 4101 V W DRILLING INC WJUuz <br /> San Joaquin'CoU>nty frr>aviron' ntaI Health Services lirii V'Well,;Permit Applicatti"On SUPPllernent <br /> JOB AODRESS: E, ,� ' PERMIT SRO:1-�iv <br /> tt 10'lft <br /> LICENSED CONTRACTORS DECLARATION (LCO) <br /> I hereby affirm that I am licensed under the provisions of Chapter$ (commencing with Section 7000) of Division <br /> 3 of the Business and professions Code and my license is in full force and effect. <br /> License* Expiration Date: . <br /> Pate: _ V come actor: <br /> Signature: Title: -- <br /> r <br /> it <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> kI <br /> _ i have and will maintain a certificate of consent to self-insure for workers' compensation„ as provided for by <br /> Section 3700 of the Labor Code, for the perforrnence of the work for which this permit is issued. <br /> ✓ 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Lobor Code, <br /> for the performanre of the work for which this permit is issued. `:My workers'corn pen sation insurance <br /> carrier and policy numbers are: f <br /> Carrier: <br /> Policy Number• /` -C-,() -- <br /> E _l certify that 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 subject to the workers' compensation laws of California, and agree that if I <br /> I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply wit those provisions. <br /> i Date: Z Signature: <br /> Printed Name: <br /> i` 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 THOUSAND DOLLARS <br /> (6100,000.),IN ADDITION TO THE COST of COMPENSATION, INTEREST,ATTORNEY'S FEES;AND DAMAGES A5 <br /> i PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, tom" C-57 licensed authorized representative),her, <br />` euenvriz f L . <br /> to sign this San Joaquin County Welt Permit A llcation o y behalf. I understand this authorizatio is valid far <br /> arra 4 year and is limited to the work plan dated on the front page of this application. <br /> r <br /> t <br /> t <br /> l <br />