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i <br /> "�41Apr-10=02 11 :34A VIRONEX, INC- <br /> APP.- <br /> NC_ 510 568 7679 P.O2 <br /> APP.-10-2m2 :212` LJ00DW1;F'D=CLYDE CCNSJL.iANT <br /> rratat n7 <br /> Joaquin County Eavilrorm e.mal Heatth Services,Unit W Well Penntf Appliradan supplement <br /> JOB ADDRESS: PERMfF SRO: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> !hereby afFi, that I arm iCWSed under the provisions of Chapter 9(cornrnencfnp with Sec'jon ?f3QQ)of Divi ar <br /> l 3 of:rye Business and Pmlessinns Cade and my lirense is in full farce and eifeet. f <br /> pimi[atlon Gate: <br /> t73te: `} 1 t l7 a Contractor. L/ n C) <br /> $4�rlAitlr6: 1 - Tide. <br /> Printed narne- 7 LI ,L,2", La '- <br /> WORKERS'COMPENSATION DECLARATION <br /> i hereby affirm under pe"Ity of perjury one of the fallowing dederations: (CHECK ALL TKAT APPLY <br /> I <br /> I have and will rnainfain a certificate of consent to self-insure for,Vvwkera'cornpanmaron,ps provided for by <br /> --_.S! :.'nr:1700 of the Lsber Code,for the WorRtarlce of the work for which this permit is iss:fed_ <br /> �I have and will maintain workers'compertsaaan insurance,as required by flection 3700 ar the Labor Cods. <br /> Tnr the r..^., or the work for whict-IN$permit is issued. My workers'Compensation insurance <br /> :�r,i �r ., i• .iiry�!�r I1tr�s are: t~- <br /> t Ca►rrsr: l l CLYt Cp-- 3x15 POlioy Number: <br /> , <br /> f 4 I'certfF(1!i-e in the�erfaemance of the work for which this pwm;t iia issLad, I shat#not employ any person in <br /> :ry rrnnnar sn;.xQ In hr,-:arne sub,ect to the workefs'compensation laws of California, and agree that it t <br /> 531au'd became suhjert to the wofkers compensation provisions of Set:tlon 3700 of the Lobar Code, I shall f <br /> fnitl:u•rii v). mply with those provisions. <br /> rIAN: ( � 'J Signature: <br /> Printed Name: 62 <br /> WARN140,FAILURE TO SECURE WORKE"I COMPENSATION COVE-RACE 15 Util,AWPUI,AND SHALL SUBJECT <br /> MN FMPLOYER TO'CRiMINAL PENALTIES AND CIVIL FINKS UP TO ONE HUNOM YNOUSAND DOL"Re <br /> tb 100,tr00.),!,+(A01IT10N TO THE COST OF COMPENSATION.INTEREST.ATTORNEY'S FES,AND CAMAGES AR <br /> �fiv,t'>Fra r07 PJ Sf�'CTr6N 7706 OF TOTE LA80R CODE. <br /> i 121 s 1 rvnk . _..�(sl9nature oflCSl ltoensed atrstortsrd rsprtset+tative?, <br /> hcrevy ptirthorit>a(pr;iii name �K1`7 �' l/Liz <br /> to sigri this Sari Joao w;h County W04 Permit AppBeatfen on My De SK I uadorstand Ails 00horlxatlon is valid for <br /> ane.0)yearana i:Qiml"WT*the work plan dated on thet'rent Page ettht,t applleetlon. <br /> � <br /> TQTPL P,03 <br /> Ir . <br /> I <br />