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Apr 07 2003 11 : 39nN VIWEX INC . 5687679 P• 2 <br /> v / Kez � <br /> San Joaquin Countty� Environmental Health <br /> Department unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �,� (/ 'COS /fLA PERMIT SR#: 62?. zk <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 0 C) a } Expiration Date: 51 3 I�C � <br /> Date: Contractor: Vi, g L 1/" <br /> Signature, Title: -3_11 ` ck_/V e_ " <br /> Printed name: 1 L G <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 forwhich 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: urC_ -� S� Policy Number: LP LI C c6 <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. �i. <br /> Date: I 022 Signature: <br /> Printed Name: S(-,,a Lk _) ,A i I-P <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 /> NTO COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N SECTION37 6 OF THE LABOR <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCS7IIcensed authorized representative), <br /> hereby authorize(print name) (ilLN, <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 /> 8-29-02 1 MI <br />