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03/22/2001 THLT 16:06 FAX 916 777 4101 V W DRILLING INC ` I IA002 <br /> San Joaquin County Envtronmenta{Hea{'tjh,,Se Vnea, J"" Well Permit Appiicationa^upptetnent <br /> JOB ADDRESS G n PERMIT <br /> LIC SED �O RACTORS DECLARATION (LCD) <br /> I hereby affiren that I am licensed under the provisions of Chaplet 9 (commencing with Section 7000)of Division <br /> 3 of the Business <br /> i and professions Code and my license is(n full force and effect. <br /> License S' / Al /J Expiration bate: {� U <br /> Dale: ,r' Or1tT8Ctdf= }( tA1 �1/'i (�f 1/7C - <br /> Signature: sx2 .�/dam Title- <br /> Printed Marne: ii / � t� <br /> / WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peCjury one of the following declarations: 4CHECK ALL THAT APPLY) <br /> have and will maintain a certlficate 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 /> 1 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 /> Carrier: 1 e - dr`(7fJ—= 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, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Latxx Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed 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 /> IN ADDITION TO TWE COST OF COMPENSATION. INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> ,(C• ,(ic e0�•4horigito representative), hereby/ .n <br /> authoriza , . <br /> �to sign this San Joaquin county Well Permit Application on my behalf. 1 rstand this authwhation is valid roe <br /> pnc('1)yBar antl is limited to the work plan dated on the front page Of this aPP60ation. ----J <br /> F- -W WD'yd WV4S'O l f"i66 L—PO—GJ L <br /> r <br />