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05/02/2005 07: 27 5105687679 VIRONEX PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: r q(V PERMIT SR#: <br /> Ln <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 /> Lioense#: —] OS(2 22 Expiration Date: OS• 3 I . OS <br /> Date: S 2- U Cont ctor A r0 n n C- <br /> Signature:— Z 64 /1 Title: <br /> Printed name: Q <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following deClaratlons: (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: <br /> Carrier: Co(1f11rou-ce a SUS r� Pollcy Number: <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 /> on Si 1 <br /> Expiration nature:9 <br /> Date: l5 0(,c <br /> printed Name: 14r)rl'e IIj <br /> �Gl r�i Gdl'fi' <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 /> AUTHORIZATION `FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I Ar�e� �,�arinq/yri (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 61t't M A , I' ) _ U'LL Ci?� CMLLT LT IST <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 /> 3-19-031 MI <br />