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02/16/2010 12:04 209469770 ' V&W DRILLING PAGE 02 <br /> JOB ADDRESS: PERMIT SR S <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and PrOfesSiOns Code and my license is in full force and 9"- <br /> License P t� , El Dade: Q I' <br /> Date: 1 . I Contractor: Zt V 1�1 <br /> Signature: Title: ' <br /> cc , <br /> Print Nerve: D "1LA" <br /> WORKER'S GOMPENSA N DECLARATION <br /> I hereby affirm under penally of perjury one of the following declarations:(check one) <br /> I have and will maintain a oertificate of consent to self sure for workers'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 Coda,for the performance of the work for which this permft is Issued. My workers' <br /> Gofmpensaltlom i and policy numbers are: /� <br /> Carrier. Policy Number., . _1„l t�,c ll% l=,l-t~� ,� <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 rrpinner so ars to become subject to the workers''compensation law of Califomia, and <br /> agree that if 1 should become subject to workers'compensation provisions of Section 3700 of the <br /> LaborCodeI sh7 forthwith comply with those , <br /> Exp. Datta: � Signature: � <br /> Print Name: <br /> wANSM:FNLUFS TO$6CURE WCRItER;'COYrEN=ATiON COVWWE IS UNLA MI-AND SHALL st MJM AN OWLO lER TO <br /> CrMMM&PENALTIES ANO CMI.FOM NP TO!'IWQOa,w ADDMDU TO THE COMT of CO iii iww 1TiON,wmREST, <br /> ATTORNEIPS Flab,AND DAMAM AS FWMMM FOR VS s WrM WM OF-IMM LAWA OODE. <br /> OTHER THAN C-67 WNING PERMIT APPUCAT10N <br /> b (Si9rultf 10 of i rap�reslntutiive) <br /> here".authofte.(in t mow) 1 1 <br /> slpn this San.baquin county WWPare t A"catbn on my WM V- 1 thts is valid <br /> thr one year and Is rimed m the work pian dated on the front page of this appttc&*M. <br /> MUM" <br /> aw2ul Slaw VK:LLPOW AFP <br />