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{ j <br /> 05/08/2001 TUE '09:49 FAX 916 4101 V IV DRILLING'INC �002 <br /> t <br /> I� <br /> } <br /> San.Joaquin County Environmental.Health ServicGe, unit IV Wiii -ermit App ication Supplement <br /> ll r <br /> JOB ADDRESS: 1i'C'7_ '1.�I I� 1 t+, . �.' �r k' ,� PERMIT SR#`Nv <br /> �O <br /> LICENSED CONTRACTORS DECLARATION (LCIS} <br /> hereby affirm that I am licensed under the provisions of Chaplei 9 (corpmencing with Section 7000) of Division <br /> 3 of the Busine83 and Professions Code and my license is In full force and effect, <br />` License / Expiration Date: o '' - <br /> f <br /> Date: D al�tractar 1`l 1LZ - _„ <br /> Signature; Title: - <br /> - �. <br /> Printed name: 0V, 4a �. <br /> WORKERS' COMPr=NSATiON DECLARATION <br /> I hereby affirm-under penalty of perjury one of the following declaratinns., (CHECK ALL THAT APPLY) <br /> I have'end wit] maintain a certificate of consent to seif-insure for workers' compensation, as provided for by <br /> i Section 3700 of the Labor Cade, for the performance of the work for which this permit is Issued. <br /> I have'and wife rnaintairr workers'compensation lnsurancc, as required by Section 3700 of the Labor Code, <br /> for theiperformence of the work for which this permit is issued. My workers`compensation insurance <br /> carner-'and e, <br /> ipolicy numbers ar <br /> Carrier: _-_ 1-' 1 =. Q C Policy Number: <br /> _1 certify that in the performance of the work for whicl this permit is issued, t sh-,ll not employ any person in <br /> any manner so ss to become subject to the workers',compensation laves of California, and agreo that if I <br /> should become subject to the workers` compensation provisions of Section 3700 of the.Labor Cade.:I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name- <br /> WARNING:''FAILURE <br /> ame: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 /> JN ADDiTiON TO THE COST OF COMPENSATION, INTERTEST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED-FOR IN SECTION 3706 OF THS LABOR CDDE,:' <br /> l y (C-S7 licensed authorizedtn <br /> reprgscntare), Iierehy <br /> authorize �' �` i � h L <br /> to sign this Sarn Joaquin County Well Permit Application on my behalf. l understand this authariaatian is valid fol <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> h <br /> �. •� 1^JC]'t4� W�US'�l EE6 1-570—i7 i <br />