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10/26/2005 18:24 5105687679 <br />uct 2( Ub 1123a Peter 1./V <br />VIRDNEX <br />5) 938-1610 <br />PAGE 02 <br />p.2 <br />San .Joaquin County Environmental Health Department Unit IV Well Petrnit Application Supp!arnent <br />JOB ADDRESS: PERMIT SRS; <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 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 4' -10SCi Q7 Expiration Date: OS -/t C)-7 <br />Date: 10 - - 0 Contractor: \.) k -r()C • <br />Signature: <br /> <br />V eL pat-, 6,-)c-i <br />nOyi Datnar \fi. <br /> <br />Title; Gt15\ <br /> <br />Printed name: <br /> <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />_ I ha Ve 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 />y I have and wit 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 />Ctif\j'e Sta--kt Policy Number L3C, i. '-..-.) 0 a•-• <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 />Expiration Date: OW '050(.p Signature: <br />Printed Name: <br />-7.5 :...'ZiriPRNSATION COVERAGE IS UNLAWFUL, AND SHALL sURJEOT <br />- ,"1:i•-.°:‘,..F1!A-IES UP TO ONE HUNDRED THOUSAND DOLLARS <br />„CTOF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />BECTICN 3705 CI: THE LABOR CODE. <br />- <br />(sin.a iure ofC-57 iicensee aut.nort2edirearezantzthr. <br />4u,r1 y Welt Permit Applus-qtion cn my behalf_ I understand this authorization Is valid for <br />carrier: <br />1.); <br />AA-AL <br />6nvrt4