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WV- •cum authorize <br />IA*01510:26 FAX 916 777 4101 V W DRILLING INC <br /> i1002 <br />San Joaquin County EnvironMent iHBalth Services, UnitiV. WeILPerrytit-AppliceitiorkSup merit <br />JOB ADDRESS: c__ ,ua .:_.:1)(-.F lo.t•• PERMIT. ; S 'R:. "2.1 /5221 <br />/ / <br />- • • • • • .. s <br />5e f c, et.c-4/,4i,c__ ezi/ie-OtA) . <br />LICENSED 'CONTRACTORS DECLARATION (LCD) <br />' .-ierety.; a-firm :mat I am licensed under the vovisicne of Chapter 9 ;commenc.,ing with Section 7C1,. i.:'; of G;krison <br />of tiv, Biri453S and Professions C.x..'a and my license is In full force and effect. <br />License #: 7d10904/ Expiration Dater <br />Date; •z/2-0/e? / . ontractdr: Vi tAi Drillinj -T-r)C - <br />Signature: 1,41_ , a Ticie: 6,14-1-a-‘2444-4-4--/ <br />/ - I <br />W-..t______ <br />Printed name: Vt hcn <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 e c.ons2..nt to self-insUre for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the 1..-3 -forrnance of the work for which this permit is issued. <br />V/ I have and will maintain worker's' compensation insurance, as required by Section 3700 Of the Labor Code, <br />for the performance of the work for wh:ch th..s permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: Oen .E.c13/CJ Policy Number: IVWC-541115517-06 <br />I certify that in the performance of the work for which this permit is issued, l shall not employ any 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 sublect to the workers compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKER-5' 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 /> ____(C-57 licensed author' erd rep rrtative}, hereby <br />I 07)1111\k,k <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />yei3r and is limited to the work plan dated on the front page of this application. <br />Narld wvvs4e1 61-vo-oL