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02/23/2001 FRI 14:19 FAX 916 777 4101 V W DRILLING INC [1002 <br /> �I' L7 <br /> Sen JoagUln County Environmental J-tealth Services,UnIVIVi We11.-Permit.AppIicatia,%Supplement <br /> JOB ADDRESS: -, n y PFRMIY SR#:•y Z5 3 �Z <br /> LICENSED CON CTORS 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 Business and Professions Code and my license Is in full force and effect. <br /> License#: �C�'0 d'7 Expiration Date: <br /> Date: Qontractor. <br /> /I <br /> Signature' �d�' <br /> Printed name: ibD b V I �Jg 1 <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 setf-insure for workers' compensation,as provided for by <br /> Section $700 of the Labor Code,for the performance oflhe 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: (Ilden Policy Number. <br /> I certify that in the performance of the work for which this permit is issued,1 shall not employ any person In <br /> any manner so as tc become subject to the workers' Compensation laves of California, and agree that it) <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 /> ($900,000.),M ADDITION TO THE COST OF COMPENSATION,iNTERE$T,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, -57 Ilconsed auth 'zed repre4gntagvei, hereby <br /> authorize LL l , <br /> to sign this San Joaquin County Well Pem'rlt Application o y behalf, I u derstand this authorixatlon is valid for <br /> one(1}year and is limited to the work plan dated on the front page of this application. <br /> c "d WOidd Wb V�°0 l 666 l-vfl-Q L <br />