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08/27/2001 MON 12:35 FAX 916 777 4101 V W DRILLING INC 0002 <br /> San Joaquin County Environ ental Health-S'erviees', Unit IV Well PsrRlit i4pplication Supplement <br /> 2 <br /> JOB-:ADDRESS: PERMIT SR#. <br /> IPV <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: <br /> C Expiration Date; <br /> Date:. �—� Con actor: + f <br /> /r <br /> Signature' <br /> U.t✓ Title: <br /> aA <br /> _ I , <br /> Printed name; �- <br /> I <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 of consent 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 <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 /> G �iZ.L. Policy Number: <br /> Carrier. � !��� �- <br /> _I certify that in the performance 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 agree that if I <br /> should become subject to the workers' compensation provisions of Section 370 of the Labor Code, I shall <br /> forthwith c mply wi- those provisions. <br /> Date: 2 Signature: <br /> - U <br /> Printed Name: JL LL- <br /> i <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 /> I L (C-57 Ikcensed authorized repres tive), hereby <br /> authorize l �rf� ,�' I ri 1 1 1�•U ���R�1 7 <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)Year and Is limited to the work plan dated on the front page of this application. <br /> 57 <br /> 6te-1 UAtAj s <br /> 17 <br />