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03/22/2001 THU 16:06 FAX 916 777 4101 V W DRILLING INC <br />Sart Joaquin County Environmental Health Se Ices, Unit IV YV-ell PetMit Application Supplement <br />I <br />JOB ADDRESS. G PERMIT SR# Dt/ <br />LI NSE �0 LCTORS DECLARATION (LCD) <br />Z002 <br />I hereby affirm that I am licensed under the provisions of Chaplej 9 (conimencincg with Section 7000} at DMs,3on <br />3 of the Business and Professions Code and my license is Irl full force and effect. <br />License #: ��cxdz'7 Expiration Dote: <br />Date: Gr ir2tCiGr: ; �i(ii i C <br />Signature: ! �/a �� Title:4'�'��� <br />Printed name: 1�–JVLw <br />WORKERS'COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of Me- following declarations: (CHECK ALL THAT APPLY) <br />I have and villi maintain a certlfic.ate of consent to s5 if -insure for workers' cornpensatiorn, as rxov;dc far Eby <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 />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are; <br />Carrier: n Policy Number: <br />_ I certify that in the performance of the work for w#iich this permit is issued, 1 shall not employ any person in <br />any manner so as to become subject to tra workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provislons of Section 3700 of the Laho; Code, 1 shall <br />forthwith Comply with talose provisions. <br />Date, _, Signature: <br />Printed Name: <br />lA ,� RMNG: 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 />JN ADDITION TO THE COST OF COMPENSATION, INTEREST, AT'TQRNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR in SI:OTION 3 01} OF THE LABOR CODF- <br />a uth <br />to sign this San Joagvin County Well <br />.—fhor4i" d representative), hereby <br />stand this authodzation is valid toe <br />One (1) year and is limited to the work plan dated on the front page of this application - <br />a, <br />F, -H WodA KV79 = O 1 666 L—pO—(�-J L <br />