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10/08/2002 15: 00 707-585-0900 VERTEX ENG PAGE 03/04 <br /> Oct-07-02 04: 21P VIR—AEX, INC- 510 jS 7679 P-02 <br /> San Joaquin County Environrrtental Health Department Unit IV Well permit Application supplement <br /> 7PERMIT SR#: <br /> JOB S;ADDRES <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am lifiessleddunder the s Code and provisions <br /> license is napue 9(commencing force a d effect.with Section 7000)of Division <br /> 3 of the Business and Pro J <br /> Expiration Date: <br /> License#: <br /> L�Ate' <br /> 1�� I �u Contractor: L) <br /> signature: c . <br /> Title: <br /> Printed name: <br /> WORKERS' COMPENSATION 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 provided for <br /> by Section 3700 of the Labor Code,for the perfon-trance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: T� <br /> Carrier: l.J`rCL4 }� r� Pa11cy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <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 /> Date: <br /> -- ( - signature' <br /> Printed Name: <br /> WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE M UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> P <br /> SROV <br /> PROVIDED FOR AMITION TO THE COST OF <br /> SECTION 3706 O THE COMPENSATION. <br /> OMPS SA ION. INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> AUTHORIZATION FOR QTHE. THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-ST ncdnsed authorized representative), <br /> hereby authorize(print name) <br /> to sign this 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 application. <br /> 8-2"21 MI <br />