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02/23/2001 FRI 14:19 FAX 916 777 4101 V W DRILLING INC 2002 <br /> San Joaquin County Environmental 4-tealth Services,U.nit:1Vf Well-Permit..Applicatign Supplemept <br /> JOB ADDRESS&D � PeRm:-'r, Ski:�d 3�3 <br /> LICENSED CONTRACTORS DECLARATION LCQ <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 /> License#: Expiration Date: <br /> Date: Qontractor. <br /> Signature: Tile' <br /> Printed name: �JO[ I 1'1 VI �►'7�'n ! - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK AL.t.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 thus permit is Issued- <br /> v/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 Aden _QG 1 e _ 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' compensalion laws of California,and agree that if 1 <br /> should become subject to the workers' compensation provisions of$ection 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.),JN ADDIT)ON TO THE COST OF COMPENSATION,INT✓cREST,A'TTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THB LABOR CODE. <br /> 1, 11 A-57114penvadauthorized r,apregentattivei, hereby <br /> authorize / <br /> to sign this San Joaquin County Well Permlt Application o y behalf I u darstand this authoflmatlon is valid fol <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> E -d WOi`I� WbV9'a l 666 l—Vfl—Q L <br />