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Jun 16 2003 1 : 16PM VIRONEX INC. 510568767S P. 5 <br /> san.l®aeTarin County Envirattme rtital He h Department Ur.it IV[Neal[ Ps"Mit APPli.ation SuPPiement <br /> y <br /> PERMIT SR#:,10 3 ADDRESS: <br /> S:�/'SGS'"`"" v -- - lJ 3 2��_ <br /> i I <br /> LICENSED CONTRACTORS DECLARATION <br /> i I7eretiy a�fnrr, ti'±at 1 am i ce7sed unde-the pr�3Idisior-�s of Ci;trflter 9 (cammEncir;) �+#h Seaton 700:)) of Dis �i0n I' <br /> 3 Df the Busijess rand i�rotessions Code anc my licei, I� in 'ull tome and effect. <br /> Expiret'.on <br /> Date: <br /> License _ <br /> r Date: <br /> I.C+ <br /> ,_ _ <br /> Signawre —.T-itle <br /> Printed naine-... <br /> 11 WORKERS' COMPENSATION D=�CL.ARATIUN <br /> I hereoy aftirm krndoT penalty of perjury one of the foiiowing deciara:ions. (CHECK ONE) <br /> e ar. will otta{n!�iri a certifi^,ate of consent,to sett-insure for work-M' ounipensatjon.ounrpen:sation. as srovidFd far i <br /> izy .4eClics 37(7© at the l_abo' Crile, for tt�e perforrr'ance of the work for vll:ia:h this r ermit is issuad. <br /> t Nava art Lvili maintain workers' compensation insurance, as required by 'cLtsan 3700 of the Labor Coda. <br /> +for trse pe or^rartice oY the work for'v;hth t°lis permit is issuer? My worKers' cort•rpt�tnsation i!isurance <br /> cxarr; r anO Pcl'+;y nWrbe;s ere: _ <br /> 15 <br /> Garrir3r: Policy Nurt�tuar. -------�_ _ _+ <br /> I c:esjity thl.+, in the peifamiance of t1 e worK fOrwhiGn INS P9-Mit is. issuesi, ! shall riot empiOy any person in <br /> any mann r so as to become 5UbjeCt t0 t.he workers'corn peri w <br /> sation jaws of Califcrnis, and agree that if I <br /> should bewme subjee:i to the workElrs' cnmP8nsetiors Plrov'rsiors of Section 3700 of the Labor Code. I stroll <br /> forthwith cornpiy°with these Provisions 4 <br /> Signature: • - ��.�'-• �" <br /> Date: _ <br /> i Printed Name <br /> I : FA LURE TO SECURE WORKERS'COMPENSATION COVE.RACIE 15 UNLAWFUL,AND SHALL SUBJECT' <br /> AN E'Mpl.rsYEl t TO CRIMINAL PENALTIESAND CIVIL FINE-.,LP TO ONE HUPlt,131'et3 THOUSAND ND[3 DOLLARS i <br /> ($'100,000.), IN IADD[TI6`d Til THE COST OF COM PENSATICN,tNTEREST,A-rTORNFY'S FEES, Af�U DY+MI:4G7tr 3 48 <br /> PROVIDE[) FOF IN SECTION 3703 OF'ENE LABOR CODE. <br /> I' AUT I"ORIZATION FOR . rHER THAN C-57 SIGNING PERMIT APPLICATION <br /> __.lsignaatt,re nfC-3?licensed authorized res�xese rrtats�ea), <br /> a Y O <br /> hereuy authnrize(print name).____A <br /> h Son Jo,a uin County Well Perritt Application on my beieal°• i understand this ;uthorizatlon is va:!d "ar <br /> tx>'ssgrs this q <br /> one(9)year and iz lirn"rted to the wart+ plan dated on the front P890 Of,MG&Pl+lir..artion. i <br /> 18-29-+)2 <br />