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2010-Nov-19 02 45 PM MUSCO FA* OLIVE COMPANY 2098360853 • 312 <br /> 11/19/2010 11;49 2094697704 V&W DRILLING PAGE 01 <br /> 2010•Nnv•19 09.11 Al MUSCC FAMILY CLIVE COMPANY 2098360852 1/1 <br /> I'�� R9 <br /> CEIV <br /> San Joaquin County CnvlronmantalHealth DepartmentUnftIVWall Permit Appliea//tlon/84ppla g L��II <br /> JOR ADDRESS. 1'701So J,.._ `Nvg�Nt PERMIT SR#: ®U/�l v p000 M NTAL HEALTH <br /> IPERMITj SEWICE,9 <br /> LICINSED CONTRAOTOR3 DECLARATION (L2W <br /> I hereby*Mrm that I am Iloeneed under the prov aiana of ChapterI(eommerift with SeClon 7000)of NVII11" <br /> 9 of the aglinsss�and�Professlons Code and my I*n5a le In full farce and <br /> a ect <br /> License# 11 �015;( Expirat nn Date: `'` �� I Z <br /> bete 1 nn actor; \V1 AC <br /> $10noture: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby aMlmh underpena:ty or perjury one of thef0llPwln9 declarations: (CHIaCK QNE) <br /> —I have end will maintaln a ceAldcete of consent to ealf•Ineure for workers'ousns9tlon,as q wdad for <br /> by 3KIlan 3700 of tns Labor Code,for the performance of the work far whleh this parmItIs issued. <br /> 11 hava:ndwll!-21M61111 1.1.10,"0 compenaatlon Insurance,as required by u 00 el the Labor Code, <br /> for the perfonnenoaofthe work for which this pelmitIslesued. MywolkaWoompormsemninouronce <br /> carr(er en ollay n era gra: <br /> Carrier: PolicyNumberr �� '/"U t1��(,n-7—10 <br /> I vertlfy that-in the Performance ottheworR forwhleh this perm uad,I mall not emplo any parson in <br /> any manner so as to become subject to the worker'camp at10ri I Wt M Callfornie, res that If I <br /> should become subject 10 the wort era'Dom psnwtlon prows ne of filen 0700 of tl a Lab r Code,I shall <br /> forthwith comply th th se provtalono. n <br /> Expiration Date: 1 8iehature; t <br /> Printed Name: ' / <br /> WARNING;FAILURG TO$SOURS WORKwRW COMPNNSATIQN CQVRRAOR 14 VNLAwFU ,AND SHALLSUDJSCT <br /> ANEMPLOYERTo IMINALPENALTIEGAND01VILFINE8UPTOONE HUNDREDTHOUSANDOOLLARe <br /> (1100,000),IN AD TI TO TItH QOGT OF QOh1PGNiATION,INTBR68T,ATTORNHY'S PERO,AND DAMAOM3 AS <br /> Pf(OVDEbFOR1 aE ON 3708 OF THE LABOROODE <br /> A TFC )RI I N ZK HAN •87 SIGNING PERMIT APPLICATION <br /> 1. Iinaturo ofO.57 a«need authorh:ed repraaardativs), <br /> harebyauthorize(pdntrime) Ul <br /> to glen this Oen Joaciuln OcuntY Well PormltAPPRcation an my behat. r understand this authorization Is valid for <br /> W6(1)yearandis Ianaed to the end'plan dated an the front pees of this applra■tten. <br /> "111,0211141 <br /> a <br /> brrozrs•aal <br /> bAOrW <br />