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07/28/2000 FRI 14:09 FAX 818 777 410.1 V W DRILLING INC 1x002 <br /> 07x/2$/00 13:48 FAX �/✓ ��� 1 03 <br /> Sah Joaquin County Environmental Health Services, Unit IV Well PerrrlltApplication Supplement <br /> JOB ADDRESS. PERMIT SR#: <br /> Tmaj , + <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> j I hereby affirm that I am licensed under the provisions of Chapter 2 (commencing with Section 7000) of Division � <br /> 3 of the Businessrand WrQh;ssions Code and my licen5c i5 in Tull force and effect. <br /> License#, ._ Lam` Expiration ❑ate-- 4=_ -- <br /> i Dais. D6 j 11 OCJ nC � <br /> Signature: ( C1t-�, Ttitet <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm r,ndE,r penalty of perjury one a1 the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will rnau+tcin a certificate of consent to self-insure for workers' campensatlen• as provided far by <br /> Section 3700 of the Labor Code, fcr the performance of the work for which this permit is issued- <br /> I ,a[ have and will maintain workers' compensation insurance, as required by SPrtion 3709 of she L40or 0-a,e, <br /> for the performance of the work fpr which this permit is issued. My workers COm�ts8tiart inasir�ce <br /> Carrier and policy numbers are, <br /> iC�F <br /> I Carrier: �,,, _._ Policy Nurrtlxer• <br /> I -- <br /> I certify that in the-performance of the work for which fhia peffflit I5 jGzuc i, t Shall wet f0fnP%ay any person Ln <br /> I any manner sc as kc) 4ae­rr1e subject to tha workers' compensation laws of California, and agree that if I <br /> should become subject t4 the wcrkem' compensation provisions of Section 37 of the Labor Code, 1 shall <br /> 10rthwitl3 corn ly with thurse prvvisiu ns. <br /> Date: �� bo Signature: — <br /> Printed Name: <br /> WARNING; FAILURE TO SECURE YVQRKERS'COMPENSATION COVERAGE IS UNLAWF=UL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES uP To ONE 14UNDRED THOL)SAI,4D DOLLARS <br /> (54UQ,4r?a.y, INl ADDITION TO ThE COST OF CC7MPENSATION, INTFREs7,ATTORNEY'S FEES, AND DAMiA8E=S AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, )IrA L IV (C-57 iicensed atuthori=ed repsntat' e),hereby <br /> autFr9rize <br /> to sign title$art J❑aquin county Wei'I Permit Application on my behalf. I understand this outmorizabon is valid for <br /> one L1Jyear and is limited to the work plan dated on the Frwit pa0a Of thls applieatian. _ <br /> 07/2$/2000 FRT 13:49 ['1'X/RX NO 58321 19 003 <br /> 07/28/2000 FRI 14:09 FAN 916 777 Aim v u, nv TTTTarr. TT,Tr rAh nh4 <br />