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12/01/2000 FRI 16:08 FAX 916 777 4101 'V W DRILLING INC 1 002 <br /> Banjos I County Prnvlronsxienta{'Healtia Serxicss,,Unit.{VI Wsl{ Perrnif.Application;$upp{errant <br /> JOB ADDRESS: PFUM1T SFW: <br /> LICENSED CONTRACTORS DECLARATION (LD) <br /> I hereby affirm that I ,am licensed udder the provisions of Chapter.9(commencing with Section 7000)of Divislon <br /> 3 of the Buslness�andrlPrro/fessions Code and my license Is in full force and effect. <br /> 11 <br /> Licensee v'7 Expiration Dates: - <br /> pate: Contractor. 17 C <br /> ^ 1AX .J' <br /> Signature: 46/ <br /> Title Printed name: In i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Suction 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> 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 policy numbers are: <br /> Carrier: JPolicy Number: fUIyC� �7 �J - <br /> I certify that in the perfotmarim 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 agrees that if I <br /> should become subject to the worker's'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date' Sig n atu re — . <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVI~RAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLQYER TO CPJMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDIMN TO THE COST OF COMPENSATION.INTEMST,A'TTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, - IC-57 A ad authorized representative), hereby <br /> anti rOrize1 <br /> to sign this San Joaquin County Welt Permit App i on my behalf. I understand this authorization is valid far <br /> pne(1)year and is linilted to the vrork I3rf tlated on the front page of this application. <br /> 9! 'd NM1A NV17S'O l SBS i-VO-Q t <br />