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11/02/2000 TRU 12:42 FAX 9177 4101 V W DRILLING INC a 004 <br /> San JOaquln County Environrnentul tieaith Service&,Unit IV Well Permit Application 5t�ptaienTe?i4 <br /> 1 r-i <br /> JOF3 AADRESS:.L ���-31 `�L''_L — -- PERPdill" SR# --.— <br /> LICENSED CONTRACTORS DECLARATION (LG-12) <br /> I hereby affirm that I aril liuonsed under the provisions of Chapter D (conlmer'rrinU with Section 7000)of Duisron <br /> 3 of the Busin/e7s�st and Professions Code and my licrnae is in full t'orcP a/nd effect. <br /> License u: l dogoAl ---. Expiration Date: _>7�•�JLy�L — - <br /> Date:—_,..1 it I • .`-•= -- ontractor. <br /> �J-�_ ---- -- <br /> Signature: ,r � / ��� — — —— — <br /> Titlot <br /> Printed nam(((e//% ox� PZ-! — -- — — — —' — <br /> WORKERS' COMPENSATION DECLARATION <br /> t heroby affirm under Penalty Of pequry one Of the following deolara tions. (CHECK ALL TI APPLY) <br /> I havo and will maintain a Certificate of:Ansent to Self-Insure for workers' -ompr--nsatiun, as prowdad for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is clued. <br /> I have and will rnairitain workors compensation insurance, as required by Seotiun 3700 of the Labor Code <br /> for the performance of the work for which this permit is issued My workers m <br /> coponsution insu(anr:P <br /> carrier and policy numbers are, I <br /> �^^,, r- )d/�I-�,,� 7 )12 Policy Nurnber.��3' <br /> Carrieri.]��7cr�cln <br /> I certify that in the performance of the work for which this permit Is issued, t shall not employ any person in <br /> ^any manner so us to become subject to the workers'compensation laws of California, and agree that it I <br /> should become suoJeot to the workers' compensation provisions of Sectj>'n 3'Y00 of the Labor Code. I shall <br /> torthwithrcornply with those provisions. 7 <br /> 111 - <br /> Date:_— a_� .-.�— Signature: <br /> Printed Narne: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGC IS UNLAWFUL,AND SHALL SUBJEC t <br /> AN EMPLOYFR 10 CRIMINAL PENALTIES AND CIVIL FINES Up TO ONE HUNDRED THOUSAND DOLLARS <br /> j$i00PR� DED FOR N ADDITION CT ON 3701,CO ST O LR.60REC ODf=.ON, INTEREST, P.TYORN[V'S FEES,AND UAMAGE�C ASi <br /> a <br /> i <br /> ( - 7lrceniod authonzcd repros ntalive), herCbV j <br /> It <br /> authorize — <br /> i Jto sign this Sao,J i C u ty Well Pormit Application on my beh I ❑ndorstand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front pag of this application_ _--- <br />