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04/19/2000 WED 09:23 FAX 916 777 4101 V W DRILLING INC r y WJUUL <br /> I V 7) <br /> APR 21 2000 <br /> EiWIRONMENIAL- t-� <br /> PERMIT / SERVICES <br /> San.Joaquin County Environmentaltlealth Services,Littivily We11 Pefmit Application-suppfem'ent <br /> JOB ADDR�ISS: �° P PERMIT' 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 Division <br /> 3 of the ausinleesss and Professions Code and my license is In full forme and effect. <br /> License Expiration Date: <br /> Date: L^--./ ornractor:r el C <br /> Title: <br /> Signature: <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 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 /> 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:_ 04 le, Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not empioy any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if) <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 /> WARMING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO OKE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), 1N ADD)TION TO THE COST OF COMPENSA-1I0N, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1 (C-37 licensed authorized 4 representative, h�y <br /> C 1# <br /> authorize L p <br /> to sign this San Joaquin County Wall Permit Application o y behalf. I understand th;s authorixation is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application- <br /> y <br />