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" 05/2Q/2010 13: 03 20946977 a�� /l V&W DRILLING • PAGE 01 <br /> San Joaquin County Enviro � <br /> nmental Health Department Unit IV Well PerrnitApplicatiOn Supplemel �!O <br /> JOB ADDRESS: �V �(� c PERMIT SR# �06006 <br /> D4 & ` <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and e <br /> License t. L c O 9 0 F Data: [� I <br /> Date: ) —0 Contractor: <br /> Signature: <br /> Title: <br /> Print Name: �YJL� <br /> r <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under penalty Of perjury 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 /> I have and will maintain workers'compensation insurance, as reuired by Section 3700 of the <br /> Labor Code, fur the performance of the qwork for which this <br /> compensation insurance card and policy numbers are: permit �s rued_ My wortcers' <br /> Carrier. (r(-r(/ ) Policy Number: 20 00 _. Q <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> Person in any manner so as to become subject to the workers'compensation law Of California, and <br /> agree that if I should become subject to workers'eOmpansation provisions of Section 3700 of the <br /> Labor e, i she{ forthwith comply with those provi ' s. <br /> Exp. Date: 1– Signature: <br /> Print Name: _bf- .I V1L�E?( L� <br /> WARNING:FAILURE TO SP_CWM VVORKErtS'COMPENSATION OovERA(. <br /> ATTORNEY PENALE IS eNLAwFaI..,AND <br /> >3HAI.L 9UaJECT AN EMPLOyEh•TO <br /> ATTORNEY'S FEES..AND <br /> ND DAMAGES AS AND CML FWCS eF To$100,007,IN ADDITION To THE COST OF COMPENSATION,INTRREST, <br /> PROVIDED FOR IN SECTION 9700 Of THE YASOR CODE. <br /> 1, , <br /> O I R OTHER THAN Cs7 SIGNING PERMIT APPLICATION <br /> re (signature of C 67 li sed authorized renresentgtive <br /> hereby authorize(print name) C U — c/edca:.� �_ ) <br /> sign this San Joaquin county Wall Permitiny behalf. , to <br /> for one year and IS limited to the work piandated on me front 1 understand this authort7atipn,is valid <br /> i <br />