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Oct-25-99 11 : 38A VIRONEX, INC. 5102660963 P . 03 <br /> Sent By: GeoSyntec-walnut CreeK; 925 943 2366; Oct-2599 11:25; Page 3/3 <br /> r.w•. <br /> P- 3 <br /> w <br /> San Joaqu►n;Couxdr E+lYitvprrrarttal H.nu,atnvissa,unit N VUtA Pamttf <br /> PpM�atyun 8yi►pie/nent <br /> Jab AODItESS: PERMrr SR#t: I <br /> i <br /> MENSED CONTRACTORS DECLARATION (L� <br /> I hereby 01%11 that f am econaed urndar the , <br /> 3 Of the Business and Proftsions Code W d my if griseus in�force&e�with Section 7000)of Division <br /> License Expirabon Date: <br /> Date: 1011 .4E_(!_Contract.- <br /> SiSrtatun:—�;�n D�'B�i�L� <br /> Title: <br /> �- <br /> PrirttaO rune: <br /> WORKERS'COMpWaAT]ON DECLARATION <br /> I hereby sill"under penalty of peryur)r one of the foEOWing dedaratrvns. (CHECK ALL THAT APPLY) <br /> —I have and wi{ rnalntain a oert*�3te of consent to selfinsure for workors'compensation,as provided for by <br /> Section 3700 Of the Labor Code.for the podarrmnce of the work for which this perrrW is issued. <br /> I have and mill maintain wvrk*M'0OMP0i tsatton insurance,as regained by Section 3700 of the Labor Code <br /> forthre er <br /> performance Of the work for which this pmit is issutrd. <br /> GaMY worhero'cornpeneetlon insurance <br /> Policy numbers era: <br /> Carrion: n((l a lir"Uy <br /> "(�,,�l�t�etity NuucWr:W_W_Q l g <br /> i certify tical In the performance of the work fur which this "' <br /> ee to any rperrltit N Isqued.{she"hat employ arty person In <br /> rtatlrtdr sc4 taeovrrte subject to the workers'ecrnpinealion taws of California,and agree that if I <br /> shoula beom4 subject fo the work6M'oornpensabon provisions of Seglon 3700 of the Labor Cotte, I shall <br /> forthwith comphy v*h MOSm provisions. <br /> signature: <br /> E <br /> — IAJ-Jta <br /> Printed Name: (�'1 d rC , h ,A-Q <br /> MIlARL1i11d:FAtLUR$10 DECURE WOMM'COMPENSATION CSA IN UNL At+YFUI,Aryp?itAll SUBJEC T <br /> AN EMPLOYER TO CR{M{NAL PENAL Ift AND CML R NES V P TO ONE Hl1M(MED nipU(-A OO ALL S <br /> yl WOW),INR IN I pfi TO THE COSY OR COWIPWATrON,INTEREST,ATTDR%p_ 'S FEES,AND LIAMAOF.S AS <br /> PROVIDED FOR M IL 3Tfia OF vTHE LAGM CM <br /> (C.sr f"aputnorasd oenras"ftare),har�Dy <br /> to srgn tnda Son Joa"county YWa PonnH Applcatiwl on sty Ootralf. I unWrsfand <br /> tMg aarthortsatlpn is vsrld for <br /> ons t env and M t 1116theimmlr dated on ttta trent •er tltlra on. <br /> so0'd "SZ:IT 66"SZ"0T TGz94t9ttL xeuoAIA <br />