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14 44 r'l 916 777\4101 V W DRILLING INC <br /> 003 <br /> r <br /> i <br /> San J aquln Caurity''Environmental Health Services,'Unit' '. <br /> IV WdIP POMIt;4'pplica#iori Supplement <br /> JOB ADDRESS: . PE-MIT SR#: Z l� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i J hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencingwith Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: ^7 _ Expirabon Date: <br /> Date: f Coy actor: <br /> Signature: Title: G;.+ <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 /> 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 performance of the work for which this permit is issued. <br /> v' I have and vuiil maintain workers' compensation insurance, 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 /> carrier and policy numbers are; <br /> Carrier: --- Policy Number: <br /> 1 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 /> should become subject to the workers'compensation provisions:of Section 3700 of the Labor Code, I shall <br /> forthwith conioly with those provisions. <br /> f 1 <br /> Date•? Signature; <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL.AND SHALL SUBJECT. <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES VP TO ONIt HUNDRED THOUSAND DOLLARS <br /> ($404,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY's FEES,Atdb DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> t, 1 A, 11 X-57 licensed authorized representstl e), hereby <br /> at[#horizL I <br /> to sign this San Joaquin County Well Permit Applioation on my behalf."I understand this authorization is valid for <br /> one(1)year and is limited_to the work plan dated on the front page of this applicatlon. <br /> J <br />