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02/20/2001 TUE 14:26 FAX 916 4101 V W DRILLING INC • rin002 <br /> San Joaquin County Environment I-Health services,Unitw Well'.permit-Application Su ment <br /> 0025Z�j� <br /> JOB ADDRESS: PERMIT: SR#: <br /> LICENSED ONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed undor the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Businnees�sf and Professions Code and my license is In full force and effect. <br /> License#: /G1D �7 Expiration Date:. <br /> Date: Z � D/ ontractor: <br /> Signature: _ Title: (� <br /> Printed name;^—A.- & J <br /> .» I <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 /> T for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 601den F-(4k, 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 to became subject to the workers'compensation laws of California, and agree that it I <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 I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), 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 /> p C-6711censed author- act repre ntative),hereby <br /> authoAxe <br /> to sign this San Joaquin County Well Permit Application on my bohalf. I understand this authorization Is valid for <br /> One(1)year and is limited to tho work plan dated on the front page of this application. <br /> £ -d WOrJ� Wtr'95�0 L 666 t—roO--O i <br />