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09/14/2001 FRI 14:49 FAX 916 777 4101 V W DRILLING INC 1A002 <br /> e <br /> Sart Joaquin County Environmental Health Services, Unit IV Well Permit Application Suppleineint <br /> JOB ADDRESS: _v Y�f �f �- PERMIT SR#: <br /> —�- z" i <br /> LICENSED CONTRACTORS DECLARATION <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 and Professions Code and my license is in full force and effect. <br /> Expiration iration Date: + <br /> License : p _ <br /> Date,. ` cop ciar: I 4,wl. L 1 - + <br /> Signature: ' Title: , <br /> Printed name' 'L- <br /> WORKERS° COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations'. (CHECK ALL THAT APPLY) <br /> _1 have and will maintain a Certificate of Consent to self-insure for wori em'compensation, as providesl for by <br /> Section 3700 of the Labor Cotte, for the performance of the work for which this permit is issued. <br /> +// 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 /> Carrier: 6ba <br /> t. Policy Num11ber: _�J _ �f~ <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 Labor Code, I shall <br /> forthwith c moly ith those provisions. <br /> Date: :_t Signature: <br /> Printed Name. <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE lS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN A0017ION TO THE COST OF COMFENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> !, - �(4 (C-57 licensed authorized representative), hereby <br /> autheriz�e <br /> to sign this San,Joaquin County Well Permit Application on my behalf. I understand thls authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this appiloatlon. _ <br />