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04/1912000 WED 09:23 FAX 916 777 4101 V W DRILLING INC � Cuuc <br /> y+ <br /> San Joaquin County Environmental-Health Services.Uniil,lV Welt Permit Applicatlon-suppiement <br /> .SOB ADDRESS: �a-O� koeSt (M1Mt?I�_L�IIJL - <br /> PERMIT. SFtl�_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Businre�s�sf and Professions Code and my license is In full force and effect. <br /> License X: /G!D D� lir <br /> Expiration Date: <br /> Date: 10 ontractor\/9►�� ! n I JJh(4 XQ CIV <br /> -- <br /> Signature: Title, <br /> Printed name: <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 malntain 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 /> ✓ 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: f <br /> Carrier.- l Policy Number: 1VWC-5qA1--59-05 <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 J <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor 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 /> ($700,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> i, {C-37 licensed authorized representative, <br /> hereby <br /> authorize <br /> to sign this San Joaquin County Walt Permit Application o y behalf. I understand this authorization is valid for <br /> one(t)year and is limited to the work plan dated on the front paSie of this application. <br /> c •� W02�� Wtr'VS'0 t 666 t-90—O l <br />