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03/24/2000 FRI 14:56 FAX 916 777 4101 V W DRILLING INC M002 <br /> 1 <br /> I <br /> San Joaquin County Environmental Health Services,Unit IV Well,Permit-Application Supplement <br /> JOB ADDRESS: PERMIT SR#:. <br /> ( <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of_Division <br /> 3 of the Business <br /> �and Professions Code and my license is In full force and affect. <br /> License#: lGr��07 Expiration Date:/.�/ <br /> Date: onlractor. JA .1 Oi- l& . -rnC - <br /> II <br /> Signature: Title: <br /> nnl.Q4.Q(.t/lL�tl <br /> �,,�,, .. <br /> Printed name:0u_l�. - <br /> / WORKERS' COMPENSATION DECLARATION <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 ofconsent to self-Insure for workers compensatlon, 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 will 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 /> r <br /> Carrie <br /> l Iden F04k, Policy Number: <br /> I 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,l"and agree that if V <br /> should become 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 /> I <br /> iPrinted 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 THOUSAND�DOLLARS <br /> (;100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, 4 (C-37 licensed a prized representetivel, hereby <br /> authoriae <br /> Q i <br /> to sign this San Joaquin County Well Permit A -i tion on my behalf. I understand this authorization i snit for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> £ 'd W02id wvr5�01 666 t-r0-OI <br />