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11/08/2005 22: 05 5105687679 VIRONEX PAGE 02 <br /> op � - <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ff �- 6 �r� (PERMIT SR#: �7_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter a ;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#: �_��� �� Expiration Date: DS - 3 I O__7 <br /> Date: I I• OCI - 0S Contractor: I r0(A<x <br /> Signature: C� .r L TICS: CYC /1'100LV4_ r <br /> Printed name: L')Cxmo,-^h <br /> - m <br /> WORKERS' COMPENSATION DECLARATION <br /> I I <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 fcr workers' compensation, as provided for <br /> by Section 9,700 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, <br /> �'�Y <br /> Carrier: 2(\, Ar- Staff Policy Number: LX (5 1 33 O-c3k_ <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. II <br /> Expiration Date: 0(0 DS'O(o Signatu e: ", <br /> Printed Nam <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES 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 /> AATHORIZATIOn FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-67 licensed authorized representative), � <br /> hereby authorize Qprint name)__Mfile_ Md—enA cSk­, J ei n&f , Ue lkn <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 plan dated on the front page of this application, <br /> 8-29.02 t MI <br /> FHO 294)2-001 <br /> 6/2.2/04 <br />