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San Joaquin County nvironmen. <br /> CONTRACTOR AU <br /> tal Health Department <br /> THORIZATION FORM <br /> Valpico Road , Tracy , CA <br /> JO B ADDRESS : PERMIT WP #19 <br /> LICENSED CONTRACTORS DECLARATION <br /> ! hereby affirm that I am licensed under the provisions of Chapter 9 ( commencing with Section 7OOO) of <br /> Division 3 of the California Business and Professions Code and my license is i n full force and effect . <br /> l" <br /> Contractor Name : V&W Drilling , lhc . <br /> License # : 7209031 <br /> 4 Ex.pi <br /> r ' on Date : 4NM/I3 <br /> 0/24 <br /> Signature : � � V Title : <br /> Print Name : a <br /> r � Date . . <br /> WORKERS ' MPENSATI-ON DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations : ( check one) <br /> 1 have and will maintain a certificate of consent to self- insure for workers ' compensation , as <br /> � provided for by Section 3700 of the Labor Code , f or the Pei lorinance of the work for which this <br /> permit is issued . <br /> have and will maintain workers ' compensation insurance , as required by Section 3700 of the <br /> Labor Code , for the performance of the work for which thIlk <br /> is permit is issued . My workers ' <br /> ompensat i =mura ce carrier and policy numbers are : <br /> Carrier. Pol icy <br /> xP. Date : <br /> certify that in the performance of the work for W ich this permit is issued , I shall not employ any person in <br /> any manner so as to become subject to the work rs' compensation law of California , and agree that if <br /> should become subject to w rk compensa io =` provisions of Section 3700 of the Labor Code , I shall <br /> f with comply` ith those provisions . <br /> Signature : ` <br /> Print Name : <br /> WARNING : FAILURE TO SECURE WORKERS' PENSAT ION COVERAGE IS UNLAWFUL , AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $ 100 % 0001 IN <br /> ADDITION TO THE COST OF COMPENSATION , INTEREST, A TORNEY'S FEES , AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTH iZATION FOR OTHER THAN C =57 SIGNING PERMIT APPLICA ION <br /> ereby a t o rize <br /> ame of F57 Li uthorized Representativ Print Name of Authorize Agent <br /> to sign this San Joaquin unty W I & Bon g Per "it Application on my behalf. I understand this <br /> authorinza tion is valid for o e ear an,.d I mited to he w k Ian dated o the front page of this applicationAY <br /> i a re C- ice ed /W orized epresen atrve <br />