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05/20/2010 13: 03 209469770 V&W DRILLING • PAGE 01 <br /> San Joaquin County Environmental Health Department Unit IV Wap PermitApplication Supplemental <br /> JOB ADDRESS: v t • ! PERMIT SR 06006� <br /> # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commend <br /> Division 3 of the Business and Professions Code and my license is in full force andith <br /> Section 7000)of <br /> Licensep. L�a Q q 0 <br /> Ex Date: <br /> Contractor: 1rt 'll C �} <br /> Signature: ' <br /> Tittle: <br /> I Print Name: Yf e ._ v 'l <br /> r <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under panatty Of pedury one Of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 Of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> xI have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the parfprmance of the work for which this <br /> compensation insurance _ rri and I. PefTnrt is issued_ My workers' <br /> ( ' �� Po cy numbers are: <br /> Garner. Policy Number: - vV _. <br /> � Q <br /> I certify that in the , <br /> Performance of the work for which this permit is issued, I s <br /> person in any manner so as to become sahall not employ any <br /> agree that if 1 should become Sution law Of California, and <br /> Labor bJect Subject to the workam,compento workers' compensation provisions of Section 3700 of the <br /> e, I sha{ forthwith comply with those provi <br /> `1 ' s. <br /> Exp. Date: a <br /> Signature: �, <br /> Print Name: i��jjDbc—r VI'L <br /> WARNING:FAILURE 70 SECURE wORK$R$'Opp1pEN9ATION OOVERAGE IS UNLAWFuLr AND SHALL:1U41ECT AN CRIMINAL PENALYMS AND CML rujim UP TO=Top 00%IN ADDntOM TO THE OOST OF COMPErt5AT1AN,u1TlLOyf, <br /> ATTORNLMS FEES.AND F.MPI.pYER TO <br /> DANrAGES AS PROVIDED FOR IN SECTION 2700 OF THE LASOR Cope, <br /> I, �T U A I R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize (st9narture of G 67 1i nsad auttl Wlzed representative), <br /> (Print name) V s <br /> sign this San Joaquin county Well Permit Applieadon on to <br /> for One P rrly behalf. 1 understand this authortmdon.Is valid <br /> Year and is llmrted to the work plan dated On the front Da <br />