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11/02/2000 THU 12:42 FAX 9107 4101 V W DRILLING INC , <br /> X004' � <br /> _ _ ° IL` s 1I : <br /> Sen JoaquEn County Environmental Viealt i Services,Unit IV Well Pormit Application Stepspielne:'d <br /> J013 ADDRESS:._-j,, 1.�C^, `1 41I '�-:' — -- PERMIT SR#:_ __ ._ <br /> LICENSED CONTRACTORS DECL4RAMON (LCD) <br /> hereby affirm that 1 ern licensed under the provisions of ChaptPr J (commerrcinU with Section 7000) of Drvisron <br /> 3 of the busin�e7sSand Professions Code and my licenbe is in full foroa and efferf. <br /> License x: /r:T0��7 —,.— t:xpiracion Date: _tt�. �E <br /> Ji I C' _ <br /> Date:—�S.-la 1.]_.•-� -- ontractor. ,CLQ- A I�-t� IC <br /> iitlo:o —__ -- - -- <br /> Signatuno: <br /> 7L -(-a4Cc/L_1Ll_ <br /> Printed name:.J����}(f CYX' .! -- -- --- — — <br /> WORKERS' CJOM ENSATION DECLARATION <br /> I hefOby affirm andel penalty of p6rprry one Ot fhe following deoInralions, (CHECK ALL THAT APP!-Y! <br /> I have and will maintain a Certifirate of consent to self-insure for workers' -ornpansation, as prowdad rw by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. i <br /> I have and will rriaintain workorz' compensaiion insurance, ns required by Sactivn 3700 of the Labor CoQ:: <br /> for the performance of the work for which this permit is issued My workers' r;ompwlsation insurance 1 <br /> carrier and ^policy numbers are, <br /> Carrier.] rG-Y}�,W!!tt 767'1112 Policy Nurn bar: <br /> �IJ' <br /> _ 1 certify that to the performance of the work for which this permit Is issusd, I shall nol 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 subject to the workers' compensation provisions of Sect n 3'%00 of the Labor Code. I shall <br /> toithwithicompiy with those provisions. ,) <br /> l Signature: <br /> Printed Name: _ ,.�I, <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENNSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEO i , <br /> AN EMPLONER 10 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 OAMACES A.8 <br /> PROVIDED FOR IN SECTION 3-rl OF THE LABOR CODE. i <br /> — �— ( edauthori <br /> - 7 lieens- md reprosPntati veJ, hereby <br /> authorize L/ !i 6 �t4�C :` <br /> to sign this Saq' J I C u ty Well Permit Application on my be f. 1 undarstarid this authorization is valid for <br /> one t1)year and is limited to the work plan dated on the front pacJe of tills application_ <br />