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10/09/2000 MON 11:00 FAX 916 777 4101 17 IV DRILLING INC &02 <br /> son JoagWn County Environmental He Ith 9(Brvioes,Unit IV Well Per Application Supplement <br /> JOB ADDRESS: `i U) C PERMIT SR#: <br /> mu' <br /> LICE- ED� CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter.Q (commencing with Section 7000)of Division <br /> 3 of the Busin�eesl-s�and P ofession$ Code and my license is in full force end effect. <br /> License Expiration Date: �/X� -- <br /> Date: Contractor vAt �� <br /> Signature: dI 1 + / Title: <br /> Printed name: 0�U �� 1/I C 'N <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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's Issued. <br /> t!I have and wilt maintain workers'compensation insurance, as required by Section 3700 of the Labor(;Ode, <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: l��(�211 Policy Number: A C-544n i =M <br /> _I certify"t 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 3700 of the Labor Code, I shall <br /> forthwith Comply with those provisions. <br /> Date: Slgnature: _ <br /> Printed Name:WARNING- FAILURE TO SECURE WORKERS' <br /> CO <br /> CT <br /> AN EMPLOYER TO CRIMINAL PENALT ES AND CIVIL FINLSOCOVERAGE UBJE <br /> UP TO ONE HUNDRED THOUSAND DOLLARSS <br /> ADDITION <br /> IN SECTION HE OCOST <br /> CODE. INTEREST,ATTORNEY'S FEES,AND DAMAGES A <br /> PROVIDED OS <br /> 1 (C-57 tit ad allthorized rapraeentakive),hereby <br /> by <br /> �� r 'l J l \) <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorisation 1s valid for <br /> one(f)year and is limited to the work plan dated an the front page of this application. <br /> 14[1Jd HHD$:0 L 666t-170-01 <br /> � d <br />