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r,F.f is eUL14 2 ❑9Pm V I RO-NEX, INC h <br /> 51R07679 <br /> P- 2 <br /> San Joaquin County Environmental Health Departrnerit Unit IV Well ermit lication Supplement <br /> JOB ADDRESS: 10 E. 12> PERMfT SR#: X43 <br /> LICENSED CONTRACTORS DEC <br /> .LARATiON (LCD) <br /> I hereby affirm that I am licensed under the provisions <br /> 3 of the Business and of.Chapter (commencing with section 7000) of Division <br /> Professions Code and my license is In full force_ and effect_ <br /> License M 0 C1 Expiration bate: 5131 avp <br /> Date: 1 J -(] Contractor: <br /> Signature: Title: <br /> Printed name: IZ -� •,• �'- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penAlty.of pelu' ry one of the following declarations: (CHECK ONE) <br /> I have and will maintain a.certificate of consent to self-uts rre for workers' compensation, as provided for i <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> i <br /> I have and well rriafni8in workers'compensation in <br /> surar; . 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 numb6rs are: <br /> Carrier: CIV 'A . I I-{- Policy Number: WPI -?i-I S y S s' <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 workerscompensation laws of California, and agree that if I <br /> should become subject,to the workers'Compensation pravisioiis of'Section 3700 of the Labor Code, I shalt . <br /> forthwith comply with those provisions. <br /> Expiration Signature: <br /> Date: <br /> Printed Name: � l <br /> WARNING: FAILURE TO SECURE WORKERS' GOMPEIV$ATION 00VER,4GE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN_EMPLOYER TO CRIM.IhALP'bvALTIES AND CIVIL FIVES UP.YO 011 E'HUNDRED THOUSAND DOLLARS <br /> (37pt],000.), IN ADDiTiQIV:TO THE COST bF GOMPEf4SATION, I,:', 3T, AT'TORNEY'S FEES,AND'OAMAGES AS <br /> PROVIDED FOR IN SECTION.370s OF-rAE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-5 L 7SIGNING PERMIT APPLICATION <br /> l' {signature of CS7 licensed authorized representative), <br /> hereby authorize(print name) P-v-,v1 <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 /> 3-19-03 1 MI <br /> Xyr - <br /> .. z:,, �. ,n :�` s'a.k, hi-..;. .� .> "i E'v �iZv'+L'4 ,� .1- A.sS; <br /> „.. �.}.,...-,,..s ..Y . .� x?l •••t,,ia d?(.,,...vi..c '�.. ..,?..,:°i,� �.t.c•,�+3.r 1Lk..,` .-;.:,cL,)...n,.+. ..:.MAC w <br /> 04/15/04 THU 13:29 [TX/RX NO 73771 2002 <br /> i <br />