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00/18/2001 FRI 09:28 FAX 916 _7„77 4101 V W DRILLING 'NC <br /> • • 2002 <br /> San Joaquin County I£nvir'oAnfinental He/t4 Sle Ices, -, V.Well Patmit,AppVGatlgn:Supplement <br /> JOB ADDRESS: iZr) W. .� �Ly ru PERMIT SiRm'00Z55-6 <br /> C� <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 <br /> �lProfessions Code and my license i5 In full farce and effect. <br /> License#: rr/cQo v7 J1 Expiration Date:VZ& - <br /> Date: '"✓ ontractor: �/8 -E) - <br /> r <br /> Signature: Title- 6,A� U <br /> Printed name: <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 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: f <br /> Carrier Policy Number. <br /> I certify that In the perfo mance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to be me subject to the workers'compensation laws of California, and agree that if I <br /> should become subject o the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date- Signature' <br /> Printed Name: <br /> WARNING: FAILURE TO SE RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAl.PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000), IN ADDITION TO HE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGE$AS <br /> PROVIDED FOR IN SECTION 708 OF THE LABOR CODE. <br /> I, (C-Ey lioerrssd authorized representative), hereby <br /> dUtharizetv ^ <br /> to sign this San Joaquin Cou ity Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to he work plan dated on the front page of this applicatlon- <br /> E .d W021d Nvvs°01 666I.—VO—OL <br />