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Jan-25-02 03:46P VIRONEX , INC . 510 568 7679 P _ 02 <br /> FADDRESS:5vaii <br /> n Joaquin County Enrlronmentel Health Servkes, Unit IV Well Permit Application Supplement <br /> 011_- IIAN%IJ 'Rd 0Srho rte PERMIT SR#: V d� 3r <br /> Tr&cy, &A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm trial I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and <br /> my license is in full forts and I:ffeCt. <br /> Llcense0 _ 7n. g aLa 'Z) <br /> l 3 J <br /> Expiration Date:_ <br /> Date �j L c� Contractor: t S C'YLlL X <br /> Signature. r�z--:,t �. l - <br /> v TIW: <br /> Printed name.. Tt2 e, <br /> i <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> j _I have and will maintain a certificate of consent to self-insure for workers compensat+on, as provided for by I <br /> Section 3700 of the Labor Code, for the performance of the work for which this permli is issued. <br /> 1�fthave 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. Policy Number. <br /> I <br /> any Malner isothe Performance on. Of the work for which this permit Is issued. I shall not employ any person In <br /> should become s ect to the subject to the workers'compensation laws of California, and agree that if I <br /> bl workers'compensation provisions of Section 3700 of the Labor Code, i shall <br /> forthwith comply with these provisions <br /> i Date• 9 V'aZ Slgnatur� 1 U 1 ( ' � <br /> _ <br /> Printed Name_ T IL-15 lca Lr�� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUE,JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.), IN ADDITION TO THE COST OF COMPENSATION.INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> (C4 <br /> 7 licensed authorized renres¢ntative), hereby <br /> .uehorly <br /> JT- ( "at2 - <br /> to sign this San,Joaquin County W011 Permit Application on my behalf. 1 understand this authortra0on Is valid for <br /> i one(1)year and in limited to the work Ian dated on qts{reel <br /> -- of this application. � <br /> 1 <br /> 01/25/02 FRI 16:35 [TX/RX NO 98511 [A002 <br />