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I I , 41V1 v W DRILLING INC <br /> @1002 <br /> Sen Joaquin CAunty Enviro-nm-.—ental W alth Services,Unit IV Well permit Application Suppfameni <br /> JOB ADDRESS-. , lw W• 11 din PERMIT SR#• <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am lieensed under the provisions of Chapter$ (comrnencinpf with Section i 000)of Division <br /> 3 of the Business and Professions Code and my hoehise is in full force and effect- <br /> License <br /> License#: TZ96>1 <br /> / <br /> Expiration Date: �}- <br /> Date: � -- <br /> r �J <br /> Signature: Title: 6. u"4411ue _ <br /> Printed name: OC <br /> WORKERS' COMPENSATION DECLARATION i <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 /> T Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and wO maintain workers' compensa6cm insurance, as required by Section 3700 of rhe 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: ' {aero Fc.4le Policy Number: <br /> _I certify that in the performance of the work for which this permit is issued, i shalt not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agnpo that if 1 <br /> should become Subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shalt <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name; <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 <br /> 370,6 OF THE LABOR CODE. <br /> I•—�- dAdr1-1 LhlSCa5,6 (C$7 fiver ed authorized reprsaentative), h reby <br /> authorize <br /> to sign this San Joaquin County Well Permit App lostion on my half. t 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 /> £ d H0�3 HV79;0 t 6661–D9-6� <br />