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Apr 01 2004 5: 13PN VIRNE%, INC 56876792 <br /> p. <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB(ADDRESS: '510 F . s+. S}ecWbK PERMIT SR#: <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#: 11 -7n -) q a n Expiration Date:_ b 3 d /o� CTO <br /> Date: L4 1 lo({ Contractor: V I. I��C7 VI Q� C <br /> Signature: S,� Q �A9� <br /> Printed name: <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 /> I 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:& 1 <br /> Carrier: -Y, 1 t , 4 4 P Policy Number: _ - �U 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 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, 1 shall <br /> forthwith Comply with those provisions. <br /> Date: Signature:_r-,( <br /> T <br /> .Printed Name: <br /> WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYERTb CRIMINAL P'ENAL;TIES 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 /> AUTHOR,I-Z'ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCS7 licensed authorized representative), <br /> hereby authorize(print name) ai, PIX �g to� L-Y1 <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 pian dated on the front page of this application. <br /> 8-29-021 MI _ <br /> cRECEIVED TIMET-wAPR. 1. ON 4: 24PM <br /> Yl3Y.flC4'kVl9M4NiS:dTM.RdMh#il4pV4C(nu4iy aruaia:pwnial <br />