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T 05/31/2000 WED 11:26 FAX 918 777 4101 V N DRILLING INC T <br /> Son Joagti�n Cn�nut, rtvirawrnerital Health Services, Unit IV-11 1{1TeII Peerrnit AQptiicatlon SuPPt$metrt <br /> JAB ADDRESS= "OL -- PERM!'T SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I a liadGude andprovisions <br /> myisi n BfChapter 9 iS In f iull s and effect eing with Sactiorl 70001 oP bivPsinn <br /> 3 of the Busines <br /> s <br /> andProfessions <br /> lGxO7 '! Expiration Date: "— <br /> I-1Cense <br /> -ontra <br /> Date: , <br /> r= <br /> title: �-- <br /> Signature: <br /> Printed name <br /> WORKSRS' COMPRNSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fel{awing declarations: ICHEGK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent tO self-insure for workers' compensation,as provided for by <br /> Seoon 3700 of the Labor Code,for the performaR4e of me work fvr which this permit is issued. <br /> V/ i have and will maintain workers' compensation insurance, as required by Section 3700 of the LQbor Code, <br /> fvr the peliormance ofthe work for which this parmit is issued. My workers' compensation insurance <br /> carrier and }policy numbe�,rs,,ars: <br /> Carrier <br /> j�� . PalicyNumber: � "�� �-� <br /> I Certifythat in the performance of the work for which this permit is issued. 1 shall not employ any parson Ir <br /> any manner so as to beo0me vabject to the workers' compensation laws of Calsfamia., and agree that if i <br /> should beoome subye(A to the workers compensation previsions of Section 3700 of the Labor Gude, t shall <br /> forthwith comply with those prOVisians. <br /> Date: .� Signature' <br /> printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE TS UNLAWFUL,AND SHjkLL SU113JECT <br /> AN r-MPLOVIEP,TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE IJUNDPED THOUSAND vOLLARS <br /> PRv oinii' IN ADDITION TO THE FOR N 4 a� a�THE AIMOfi CODE. <br /> ON' INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> O <br /> (C-5+ T lioonsed author ad rep r ventative), lierehy <br /> E, r <br /> rtutharlxa <br /> to sign this Sart.loaCItlirr County welt permit Application 01i mY beh*lf. I understand this authartzatien is Valid for <br /> ane l3 Year and is limited to trio WOfk plan elated on the frorrt page_of thls appiiC tion. __ <br /> c •d <br />