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09/21/2010 10: 35 2094697704 V&W DRILLING PAGE 02 <br /> San Joaquin County Environmental Health Department Unit N Weil Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter g(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and a ect. <br /> License #: t�Q9 0 E <br /> ,� \xp Date: <br /> � Vlj�t (JY a <br /> Date i �(,,/ fir! (, Y► tll�1�� �C <br /> Co tractor: <br /> Signature: Titre: 71 „i c�7 <br /> Print Name: °'+ V 1 (p ( ► l <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workars' compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I 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 this permit is Issued_ My workers' <br /> compensations innsurM <br /> and policy numbers are.- <br /> Carrier; <br /> re: '1 j� <br /> Carrier; I%IfILt t_ t t- Policy Number: ��'(/; 0 tQ�— cq <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if t should become subject to workers' compensation provisions of Section 3700 of the <br /> LaborI sh 11 forthwith comply with those provi ' ns. <br /> 0 <br /> Exp. Date: QX� Signature: �� <br /> Print Name: r bb!f r�- <br /> WARNING:FAILURE TO SECURE WORKER&COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CMWk^L PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE DOST OF COIIVENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE_ <br /> �O I R OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I' (signature of P-57 ' sed a ed re o <br /> hereby authorize(print name) ^ p/ <br /> ��'� P <br /> fn <br /> sign this San Joaquin county Well Penn plication on my If. I understand this authorimtion is valid <br /> for one year and is limited to the work plan dated On the front page of this application, <br /> w�PCi ,TM <br />