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Jan 23 2004 2: OGPM VIRONEX, INC 515G6` b'/5 F• � ISan Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement JOB ADDRESS: PERMIT SR.##: l LICENSED CONTRACTORS DECLARATION (LCC?} I hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and affect. License#: —7 S �" Expiration Dare: Date: i I ER 3 f `{ Contractor: lJ�I/Zo n f,X C- Signature• r 1,pb L.�/V'� Title: 1 � 0." LIV Printed name: WORKERS' COMPENSATION DECLARATION i - I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) _I have and will maintain a ceftificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. _ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work fo,,which this permit is issued. My workers'compensation insurance carrier anC policy numbers are: i Carrier: Policy Number: Q52 I certify that in the performance of the work for which th!s permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date:_ I Signature: Printed Name: -Ta { LZ WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5400,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708"OF THE LABOR CODE. AUTHORIZATION FOR QTHER THAN C-57 SIGNING PERMIT APPLICATION ` — (signature ofC-57 iicensed authorized representative), I 4 i i hereby authorize(print name) tJt`',-v t j to sign this San Joaquin County Well Permit Application on my behalf. I understand this wiuthorizaticn is valid for Lj one 11) year and is limited to the work plan dated on the front page of this application. e-28-02 I MI .. . as � . ' r ,t I�i .. .<•,.: 1 .1 ..... .. ... ..