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03,'08,'2001 TIIE 09:49 F-A-1 916 i -4101 V W DRILLING INt' ?002 <br /> San Joaquin County Environmontal Health S,ervicee, Unit IV wf 11.Permit Application Supplement <br /> � <br /> JQB ADDRESS:- ,�? ��,ll �_� �' � ,' .` r; �- PERMIT SR#` D0 (P � <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I <br /> 1 hereby affirm} t#Tat I am licensed under the provsions of Ch,!�pier 9 (Co nmencivg with Section ,000, o` Division <br /> i 3 of the Business7/and <br /> ,Prrollessions Crxie and my license is in full force and effect, <br /> License#: F_xpiration Oate' <br /> j dste: 2 ` cntraztor t7 1 �r7 C <br /> r <br /> Siynat[1re: Title: 'I�✓Lr <br /> Printed name: [' <br /> WORKERS' COMPENSATION DECLARATION <br /> f } <br /> I heraby aMrm undar penalty of pe,jury One of tt)e following d6daratin:s: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of;nnsent to self--insure for workers' compen$ttlon, as provided for by � <br /> Section $700 of the Latzer Cort-, fnr the performance of the work for which tris perrrl'tt i5 issued. <br /> I have and 1Ni i maintain workers' compensation Insurance, as required by Section 3700 of the labor Cade, <br /> for the pertormance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and polioy numbers are; <br /> Carrier: Policy Nwrnb®r: <br /> I _i certify that in the p,Irfolmanco of the work fcf wftich this permit is issued, i shall not employ any person in <br /> any manner so ss to become laws cf Caiifaini2 and agrees:hat if 1 <br /> should become=u'3jevt to the workers' compensation provisions of Section 3700 of the Labor Code, I scall <br /> fork;with corrp,y w;th those prov;,Dons. <br /> I <br /> Date: Signature: i <br /> Printed M1fama• <br /> f <br /> ( WARNING: FAILURE TO SECURE WORKERS*COMPENSATION COVERAG3E le UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL,FINE$$ UP TO ONE HUNDREU THOUSAND DOLLARS j <br /> ($1 0,000.), IN ADDiTiON TO THr;COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 QF THE 1-ABOR CODE. <br /> _(G-$7 Iiaensed authorized represcrrtative), heretry <br /> to sign this San JOAA0"County Well Permit Appliaatign on my behalf, l understand this authorization is valid fw <br /> one t1)year and is limittid to the work plan dated on the front page of this aPpliCAti*r)_ <br />