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Jan 05 2004 10: 48 VIRONEX INC. 5105687679 _�— p. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 361g0 YUbr4-y -TLOZ:: i li-A v _ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONLCD <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7'000)of Divisi n <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: ?D 01 D� -71_ Expiration Date: J 1-bi aco S' <br /> Date: I S o Contractor: v 4 fLb YVA-x <br /> Signature: <br /> Printed name: fL I S L.v)1 <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: <br /> Carrier: policy Number: W& IDS IS 3 t� <br /> I certify that in the performance of the work for which this permit is issued, i shall not employ any person i <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 /> Date: t p Signature• cj� <br /> - � <br /> Printed Name: -T 2l <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 /> ($700,000_), 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-67 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name} -e{ a <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!MI <br /> 1 <br />