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11/02/2000 THU 12:42 FAX 916 777 4101 V W DRILLING INC Z00.4 . • <br />San Joaquin County Envirorimeritbi Health Servir..:c!..,, Unit IV Wall Pormit Application Supplement <br />JOB ADDRESS:. <br /> _ PERMIT sR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) _ <br />1 <br /> I hereby affirm that I am lioensed under the proviions of Chapter 0 (commerrning with SeGtion 7000) Of Drvision <br />3 of the Business and Professions Code and my iicense is in full force and effect. <br />License # <br />Cixpiration Date: _y <br />: 17(906/6/1 _ --- <br />Dil c.,-,,.1.,\. _ <br />ontractor: ,\Ltil iiillif <br />1 <br />Signature: .*i(.1_a- . df:12.11...)..___ _ _ _ Title: L -/./t,a tc./1.".11_/ , . ._ <br />Printed name; .jpek,FIL <br />! WORKERS' COMPENSATION DECLARATION <br />i I liroby affirm Lindai penalty of perjury one of the fc:Ilowing ciecil:31-ilipn5. (CHECK ALL THAT APPLY) 1 <br />I havo and will maintain a certificate of c.Jorisnt to 5&f-inSure for worker compensation. as prowdeci fc <br />,r iiy <br />Sion 3700 of the Labor Code. for Ine perforrmince of the work for which this peirnit is n;stied. <br />I have and will rnaintain workers' <br />compensation insurance. F,s required by Section 3700 at the Labor C.;cd.7! <br />( <br />for the pertormaiice ot the Work for which this permit is issued My workers' compensation instance I <br />Gamer ath fip.fyie ro. Number: -.111.. ' 9 etyglii: _M5 _.._ 1 <br />carrier and policy numbers arer <br />Policy _— <br />I <br />I <br />I certify that in the performance of the work for which this permit is issued, I nhall not employ <br />an person ii) <br />I <br />any manner so as to become subject to the workers' compensation laws of California, and agree that it I <br />i <br />should become subjeet to the WOrkerS' cornoensution provisions of Section 3700 of the Labor Code,. I shall <br />. .7/ <br />I forthwith comply with those provisions. <br />. <br />1 <br />i Date__i I <br />_'. <br /> <br /> <br />__ $ i g n a t u r 1_il7.121e- , <br />. <br />7 <br />Printed Name: 1 e_._. <br />I <br />---___ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE <br />is UNLA D SHALL SUEJEc i <br />1 AN EMPLCAER 10 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />IN <br />ADDITION TO THE COST OF COMPENSAT1oN, WTERES-r, ATTORNEY'S FEES, ANL). <br />DAMAGES <br />ii <br />i <br />i \ PROVIDED FOR IN SECTION 370 OF THE LABOR CODE. <br />/* <br />I <br />, k 7 Ircentadluthorifed reprep,-Titaliva), ilecctiy <br />Ilk-7/11jzt - <br />1 <br />i <br />k <br />/ ( <br />_...___.• <br />autharizo le — <br />to sign this San:ljoa <br />ty Wall Permit Application on my bottklf. I undorstaml this authorization is valid kr: <br />one (1) er and is limited to the work plan dated on the front page <br />.of this application. ____ _ __—