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04/30/2600 14: 58 9255211434 VIRONEX SF PAGE 02 <br /> 04/29/2008 02:45 9253715 <br /> GEECON - EAST $A* PAGE 02102 <br /> San Joaquin County Environmental HealthDepartmentUnit IV Weil Permit Application Su pigment <br /> JOB ADDRESS:7, /0 S. �G, `/�l� ITi PERMIT SR#: ©� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing wqh Section 7000) of Division <br /> 3 of the Business end Professions Code and my license is in full force and effect. <br /> License#: Expiration Date: Ds- s`' 09 <br /> Date_N2D Contractor: te 1r0(1� <br /> Signature: C.+�"^a "ATRIS: (Y1Ul�a�et- <br /> Printed name: UtC�a Qm QlT� <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 Soctlon 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:&� zo---r —Policy Number, <br /> 1 certify that In the performance of the work for which this permit Ia 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 H 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 /> Expiration Date: kbmSignature: <br /> Printed Name? <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatura ofC-57 licensed authorized reprosentddW), <br /> hereby authorize(print name) 1K es l Qu s$C(1 cr GEUM Corgultglyi-s <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 dates an the front page of this application. <br /> a-29.021 Mt <br /> EHD 29-m.-0at <br /> eavoa <br />