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authorize <br />JAW :26 FAX 916 777 4101 V W DRILLING INC E002 <br />San Joaquin County Environment 1 Health Services, Unit IV Weil Permit-Application Stip ment <br />Joe ADDRESS: 11. 4.0 I" L tc _ '' I. b I PERMIT. SR*: "2:f 5i; <br />,, <br />i, / <br />el <br />/ <br />5&04, <br />LICENSED <br />€A) eeiS/e-o <br />ONTRACTORS DECLARATION (LCD) <br />iereby affirm that I am licensed undor the provisions of Chapter 9 (commencing with Section 7000 of Divison <br />i; of the Business and Professions Code and my license is In full force and effect. <br />Lic.ense #: 7C9090 Expiration Date' <br />Date: 'I2/0 I . ontractor: <br />, <br />Signature: /AL ,11 <br />Printed name: th thrf <br />/ <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 V nsent 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 wirl 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 arid policy numbers are: <br />E03)C, Policy Number: 1U1V6-51-17--65 <br />I certify that in the performance of the work for which this permit is issued, shall not employ an person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if 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: Signalers: <br /> <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 />($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 />Title: <br />Carrier: <br /> (C-57 licensed author - ad repr Te rrtative). hereby <br />to sign thls San Joaquin County Well Permit Application on my bohalf. I understand this authorization Is valid for <br />.one (1) year and is limited to the work plan dated on the front page of tills application. <br />1^11:Pr3d Vria'VS , 01 6661-V0-01