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z�� 1 • i 14:19 FAX 916 777 4101 V W DRILLING INC <br />A++6 i � I✓ � t �i' # <br />San Joaqutn County Environmental Health Services, Unit:IV Well: Pennit,.Appiicatipn Supplement <br />JOB ADDRESS: 00A)GfML Prpwl SR#: O 5 31-Z <br />3 � 3 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />2002 <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section? 7000) of Dhiision <br />3 of the Business and Professions Code and my Iioense Is in full force and effect. <br />License #: <br />Expiration Date: � 0/ <br />Date: ontractor <br />Signature: ZA, A, Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a cerNflcate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance offhe work for which this permit is Issued. <br />V/ 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 pe;icy numbers are: `' <br />Carrier: Y%��� _ Policy Number: H/ <br />I 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 subject to the workers' Compensation laws of California, and agree that it J <br />should become subject to the workers' compensation provisions of Section 3700 of the Labo,- 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 />)N ADDITJON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />-5711censad authorized repre4entatfvej, hereby <br />J <br />authorize lit - <br />to sign this San Joaquin County Well Permit Application o y behalf. I rstand this authorixatlon is valid fo-r <br />one (1) year and is limited to the work plan dated on the front page of this appiloation. <br />E .cl HOS HV7S' O t GSG L—Ve—O <br />