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Jul 22 2003 9: 47 VIRONE# INC. 5105697679 p. 2 <br /> • • <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: T10 E. McLq Ytolia St. , Sfb4c-fan PERMIT SR#:��__ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereoy affirm that I am licensed underthe 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#: ,jZQ J _ Expiration Date:�� '� I r o a J <br /> Date:. J�0� Contractor U tt'f!_OVIP.J_x' L .•ig � _ <br /> Signature:. Jaytom.. ldy�,y� Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declaratiors: (CHECK ONE) <br /> I <br /> I have and will maintain a ce tfirate of consent to self-insure for workers' compensation, as provided fur <br /> by Section 3700 of the Labor Code, for the performance of the wort:for which this permit is issued, <br /> I have and will maintain workers`compensetlon insurance, as required by Section 37,111 of the Labcr Code, <br /> for the performance of the work for which this permit is Issued. iviy workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: �ra A;A-C yC 1� �PolicyNumber.—ILAD .- <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. <br /> Date: _ 2' Signature: <br /> Printed Name: -L(L- <br /> VJARNIN13: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU9JECT I' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND Cl FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),IN ADDfTION 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 tJ1 MER THAN 0-57 SIGNING PERMIT APPLICATION <br /> '.+�",�_ _ (signature ofCd7 licensed authorized representative). <br /> hereby authorize(print name)_M0.V' wr,�.0. <br /> — —'- <br /> to sign this San Joaquin County Well Penrit Application on my behalf. 1 understand this authorization Is valid for <br /> one 11)year and is Ilm lied to the work plan dated on the front page of this application. <br /> L 6-29-D2/ML ---- -- --------- —— -- <br /> i <br />