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Sep-04-01 11 :36A VIRONFX, INC . 510 m68 7679 P.02 <br /> Sen Joaquin County Envirowwntal Health Swvk4s, Unit IV Well psrrrlit Application Supplement <br /> JOB ADDRESS: PERUIT SRIF: <br /> LICENSED CONTRACTORS DECLARATION (LCDI <br /> I hereby affirm that t am licensed under the provisions of Chapter 9(commencing with Section 700D)of Division f <br /> 3 of the Business and Profession:Coda and my license is in full irate and effect. <br /> License -- GSG1(�"_ _Expiration Date_ 1 c�c1 ) <br /> Date: I L41 O Contractor: ( !IonzLy <br /> Signature: Title: <br /> Plitt nailer <br /> WORKERS' COMAENSATM DECLARATidN <br /> t hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I <br /> I have and will maintain a certificate of consent to self4nsurre for workers'compensation, as provided for by t <br /> Section 3700 of the tabor Code. for the performance of the work for which this permit is issued. 1 <br /> c_1 0Y and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> _._._for the performance of five work for which this permit is issued_ My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Policy lliu lber: <br /> I certity that in the performance of the work for which this permit is maued, 1 shag not employ any person in. <br /> any manner so as to bevorne subject to the wo*em'compensatron taws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the tabor Code. I shall <br /> forthwith comply with those provisions. <br /> iDate: _ ,� Signature: <br /> Printed llama• _f 2t l e._ <br /> WARNING:FAILURE TO SECURE WORKEIIS'C w),ENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT ! <br /> AN EMPLOYER TO ClUMNAL PENALTIES AND CML FINES UP TO ONE HUMORED THOUSAND DOLLARS <br /> (:100,000.),IN ADWTION TO THE COST OF COKKNSATIDM,INTEREST,AT'TORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (C-57 I"ristsd authorized raprasentativei, hem-by <br /> authert <br /> to sign this San Joaquin County Well Penult Application on my bohaif. 1 und♦rstand this authorization Is valid for <br /> r <br /> one 1 Rsr and is United to the worir plan dated on the front~of this awlicatton. <br />