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VIKING DRILLERS, INC. 19163721337 02/05/2009 09: 10 #899 P. 002/002 <br /> Received: Feb 5 2009 03:09pm <br /> 02/05/2009 15:02 FAX 209 9400021 la 002 <br /> San Joaquin County Environmental Health Department Unit 1V Well Permit Application Supplements! <br /> JOB ADDRESS: �/T� ��`j�/ <P&PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chepter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License A:: . 476668 <br /> Exp at 07/3 /2009 <br /> Date` ebruar o5, W6Cora r. <br /> Signature: Title: Presi nt <br /> Print Name[ Sherry Montoya <br /> WORKER'S 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!cpnsent to sell-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 /> X I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for Nie performance of the work forwhich this permit is issued. Myworkers, <br /> compensation insurance carrier and policy numbers Are: <br /> CanienSeabright InsuranecpalicyNumber BB 1061686 <br /> I certify that in tiie performance of,the work forwhich this permit is issued, shall not employ any <br /> Pa <br /> In any manner so as to became subject to; e;wor compensatlon law and <br /> agree that if I should become subject to workers' ompensatia nisi o ' t 37 aft <br /> Labor Code, 1 shall forthwith comply with those p visions. <br /> Exp.Datet 04/09 Signature: <br /> Print Name.. Sherry Montoya <br /> WARNING:FAILURE TD eECURE WORKERS'COMPENSATON COVERAGES UNLAWFUL,ANO SNALL BUBJECT AN P[APLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FiNies UP TO S7pe,epo,IN ADOMON To71E COST OF coMPENSATION,INTEREST, <br /> ATTORNErS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 9208 OF THE LABOR CODE. <br /> AUTHORIZATION FOR QTHER THAN C�7 SIGNING PERMIT APPLICATION <br /> She Montoya (eig tun3Of CZ7licensed authorized representative), <br /> hereby authorize(Print name) ✓.e M� �; ,to <br /> sign this San Joaquin county Well Permit Application an my behalf. I understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> erzwevMl. <br /> EI®2001 fIZ07 <br /> WE PGALQT pp <br />