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Nov-21 -02 03_ 56P VIRONEX, INC . 510 568 7679 r . vo i <br /> I <br /> n Joaquin County Environmental Health Departm;;;PERMIT <br /> UIV Well Permit Application Supplement <br /> JOB ADDRESS: &Y,�u &e NSR#E: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am 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# o Expiration Date: <br /> Date: i i r' i.'n _Contractor: 0 Y)e-x <br /> Signature: _ �? �illL� -� Title: <br /> Printed name: P_ <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 /> LZI 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: <br /> Carrier; .(T `] � �— Policy Number: <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: IaL Signature: _L <br /> Al.c5— _ <br /> Printed Name: 11 G <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 THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION 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 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l� <br /> Q� /1`�,`��C� (signature ofC-57 licensed.authorized representative), <br /> V <br /> hereby authorize(print name) JO n <br /> to sign this San Joaquin County Well Permit Application on my behaid 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 /> 8-29.02 1 MI <br />