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Sep 08 2003 8: 49 VIRONEX INC. 5105687679 p . 3 <br /> 09/D3/03 07:03 FAX _ - QI 003 <br /> San Joaquin County Environmentai Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: RAU 116, enrr 1-4-v . S�G�!Iz� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION ( CD) <br /> I hereby affirm that I and licensed under the provisions of Chapter 9.(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 Expiration Date: �I wl I o�oC>S <br /> Date: �y3 Contractor: 1 Q o rl. N <br /> Signature'9yyt/�=L11'"�--� i---�^- 5-' —Title: <br /> Printed name: Ac <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 for which 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: C \ - l <br /> Carder cr Y-CLM-)l )f J"�Gt✓lL Policy Number: LLX�105 1 '5- <br /> I <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 it I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,I shag <br /> forthwith damply with those provisions. <br /> Date: t _5e 1 O� Signature: <br /> Printed Name: �2���— <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 THOUSANDDOLLARS <br /> (S1D0,000.), <br /> IN AODITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR <br /> OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 (� �1/�A.y�'�. ��'`-1V�`J-oL� U-�� (signature ofC•57 licensed authorized represaatativei, <br /> hereby authorize(print name) J TL-V� :'C'A <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 /> 8.29-021 MI <br />