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10/08/2002 15: 27 707-585-?q00 VERTEX ENG PAGE 63/06 <br /> Oct-07-02 04: 21P VIf EX, INC. 510 8 7675 P.02 <br /> San Joaquin County Environmental Health Department Unit IV W <br /> PERMIT SR#: <br /> ell Permit Application Supplement <br /> JOB ADDRESS' <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> I <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License*: — <br /> Expiration Date: <br /> Date: I�` u Contractor: i _0 <br /> Title: <br /> Signature <br /> i <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> f I have and will maintain workers'compensation insurance, as required by Section 3700 of the Obor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. 7` CiJf}� - Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in II <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions- <br /> bate: — Signature: — <br /> Printed Name: <br /> WARNING. FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL,FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100Ao0.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature cfC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign thin San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this aPPIiCaHon. <br /> 8-29.421 M I <br />