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LI 5 -03 Contractor: <br />;,• <br />Dates <br />15 2[104 2: 09PM VIr NEX, INC 51i-4 97879 p. 2 <br />)) ojort <br />San Joaquin County Environmental Health Department Unit IV Well ermlt lication Supplement <br />JOB ADDRESS: In E. PERMIT SR#: ec3Taq-:. <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affi; i that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the BUSH ass and Professions Code and my license is in full force and effect. <br />Expiration Date: 573 L /'°-t <br />aDvu.),( <br />License #: <br />Signature: <br /> <br />Title: c.527):: <br /> <br />Printed name: -Fru,svLo, LL.yrI% <br /> <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 performance 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: <br />Carrier: e..-71"-a-n Policy Number: k.0C-1 7 LI "S Li S <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 />Expiration Signature: <br />Date: <br />Printed <br />L12S - On- <br />Printed Name: -1-1/...A,<-)\e‘rx <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 />($100,000.), 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 />/4).ka_ (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) PIZA-VA CLUt k•‘A-- <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 />3-19-03 / MI <br />04/15/04 THU 13:29 [TX/RX NO 73771 Z002