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03/29/2000 WED 11:35 FAX 916 777 4101 V W DRILLING INC 0002 <br /> San Joaquin County Environmental Health Services,Vinit lV Weil ion-Supplement <br /> JOB ADDRESS: PEFtMM SR#: <br /> LICENSED CONTRACTORS DECLARATION {LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Dmsbn <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License 6.. /-r1C906" Expiration Date: ��.30L <br /> Date: ontractor. 1r�Avi Dr7 h-Z <br /> Signature: 1 Title- <br /> Printed name: OJ� _ <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 will maintain workers'compensation insurance, as required by Sectlon 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:_-hiFaale, Policy Number: <br /> k/ <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 1 <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 /> 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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 8706 OF THE LABOR CODE. <br /> 1 (C-57 licensed authorized representative),hereby <br /> authorise nal Ca <br /> C" <br /> to sign thi6 San Joaquin County Well Permit ApplicaH o my half. 1 understand this authorization Is valid fa <br /> one 1 ear and Is limited to the work plan dated on the front page of H+Is application. <br /> E .d WOLi� NVVG=O L 666 L—VO-O L <br />