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11/02/2000 THII 12 12 FAA 918 777 4101 V W DRILLING INC <br /> �J 00-t <br /> i <br /> Sin,loaqu'n County t;nvrronttYentt;5 Fte.lt4r Ser�rccs Unit IV Well Fcrr-nit Applcc-ctrori -t,p—nI it',,-2,t � <br /> i <br /> JOB ADDRESS �J �^ �1�1 ����L 't � , PF-RUPT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby aft+rm Thal fain lu,Cnsed under the prov�t icns of Chaptnr-0 (ccuirnierf-erre f with Sertron '00p) of Drvtsrnn <br /> 3 of the eusmP5s aricl PrOessions Code and my 1rcianbr, is in full torr,,- arld ef(pci <br /> License i1 !c90%o'l t`xp,ration Date. <br /> Date • ontractorto J`1�� <br /> signature �Trt10 /'IPI6ZLc�lpltJ� <br /> Panted name �Jo�� .]l f [h_' <br /> WORKERS' COMPENSATION DECLARA rrON � <br /> ! he-ioby zi firin undr;r penalty of ptrj )r1 onr of the fc+flowing (CF4ECK ALL THAT APPI.Y► <br /> I <br /> I novo 2nd will rrtafrrtarn n Of tO 5&f-1n',0rC fi)r mjorM eit as pi ov clad fr�r i_iy <br /> Sr•ctton 3 700 of the Lib-)r Codi_ fur lI1E p2rtorm ince of 01r1 wtjrk Tur whini this per i nit i, 1°600:. � <br /> 16cave arui will frouitain s%arkcrs' Cumpcnswlon mlwrAnce as rCquir4?q by SoQtiuri 3700 of trio Labor(,aCti { <br /> w for the perfoif-ance of the woFk for v%hcch thi, permit r5 issued My workL3rs' f ompc:nsuLion insrjianrp f <br /> carnor and pDlcc y nurnbcrs are I <br /> �'" 11 p i <br /> Carnera„� f(� I h!. Policy Number ��Ja` 1 L Ial QX)a <br /> I cert/ that in the rforrnanrP of the:work for whfrh this permit i% ibsucci t ,hwi nnl ens to an ei son �i, <br /> _ certify P� P Cr Y Y P <br /> 8ny mdoner 7Sa as to becorne subject to the workers coil)pcnsation laws- of Califorriki an,1 agree that it I <br /> should become-suNact to the workers compeosatiah provisions of;;ercttflri 3100 of the Labor Code I trail <br /> forthwiW- ) <br /> tnrcornply with thnse provisions <br /> Date _ � tSignature _ ?L :�f {7 <br /> Footed Name _ Irl ` ��. <br /> f J <br /> I WARNING FAILURE TO SECURE WORKERS COMPENSATION COVERAGIv IS UNLAWFUL ANO SrVALL.St3r3J`c ; <br /> AN EMPLOYER 10 CRIMIRAL PENALTIES AND CIVIL. FINES Vp TO ONE HUNDRED THOUSANZ) I]OLL.ARS <br /> ($100,000 ) IN ADDiMN TO THZ COST OF COMPSNSATIM INTEREST, ATTORNEY'S FEES,ANN t7A)LhA0Er a°, <br /> PROVIDED FOR IN SECTION 37055.OF THE LABOR COVE <br /> i c <br /> 7 lreens:ed., Whorircd repmsentatrva), hereby i <br /> tT- <br /> } i <br /> e I <br /> r / <br /> to sign this sal"a j a+ s C u ty Wollperson Applreatcon on my doh 1 und�rstartd thio authnrst,;tcor�cs`olid fc, <br /> onv{91 year and is limpets to the work plan dated on th* froiet pat*of titres applccal+Ur?� <br /> r <br />