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z Otis IBrYOQl Pt3E> 00:49 FAX 916 777 4101 V W DRILLING INC <br />San Joaquin County Environ`mt ental Health S.ervicea, Unit IV Well Permit Application Supplement <br />JOB ADDRESS:) '''1�7 ',9,� 11 f ���}�i�� �� PERMIT SR <br />.l <br />� � <br />;L'l, iV 1 L I� <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />Z 00? <br />I hereby affirm that I am licensed under the provisions of Cheplel 9 (cot-+mencing with Section 7 0C4) of Division <br />3 of the Businfeess and Prroi4essions Code and Illy license is in full force and effect. <br />License #: 164 1 �) 7 Expiration oat.' <br />—a r... <br />�I <br />Date: _-- <br />Signature: _66 <br />Printed name: <br />���1 I�nlhi C <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declaratin,,s: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to Jeff -insure for workers' compensation, as provided for by <br />i T Section 3700 of the Labor Corr, for the performance of the work for which this permit is Issued. <br />I have and will maintain workers' compensation lnsurancc, as requirea 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 nurnbers are. I / <br />Carrier: lid P,t� EVA ---Policy Number: Uii,16-5" '7 -Q t3 <br />_ 1 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 sabject to the workers' compensation laws of California, and afire: that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comp'.y with those provisions. <br />Date: <br />Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' GOMPENSATION COVERAGE 18 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100.000,}, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3706 OF TH1= jASOR CODE. <br />•37 licensed authorized representative), hereby <br />authorize <br />to sign this San Jontiuin County Well Permit Application on my behalf. I understand this authofiaatian is valid fos <br />one (1) year and is limit©d to the work plan dated on the front page of this appliCatiOn. <br />I;:.0 L^JCJd� NV 1, S• 0 i 666 l- 0-7J l <br />