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"""uzoul i4:nd 92552111434 VIRONEX SF <br /> PAGE 02 <br /> 04/29/2008 02: 49 9253710 GEOCON - EAST BAO PAGE 02/02 <br /> 1r /S-/0�o ( ow <br /> Sn Joaquin CeunryEnvironnmental Health Department Unit IV Well Permit Application supplement <br /> AORESS:_ <br /> PERMIT SR#: D7 rbV <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that am licensed under the provisions of Chapter 9(commencing with Section 7000),of Division <br /> 3 of the Business end Professions Code and my license is in full force and effect. <br /> License#: f, �2� F-virstion Date: IDS- S l . 09 <br /> Date: ' '' V6 Contractor: � <br /> �0(1 <br /> Signature: I � Q2& tAa sl TWO; V�TICe ;�`IQl1Gt�2R <br /> Printed name: f7tf A clirnC1/T-h- <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 perfOrmanoe of the work for which this permit is issued. <br /> I have entl w 11 maintain workers'compensation insurance, as required by Section 3700 of the Lobar Coda, <br /> for the performance of the work for which this permit is issued, My workers'compensatlon insurance <br /> carrier and policy numbers <br /> '� �p are:,, / �f 1 <br /> Carrier. E 11 r."""- � 6tb!f Policy Number; <br /> I certify that-In the performance of the work forwhich 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'wmpenzation provisions of Section 3700 of the Labor code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:.NVQ I' Signature: ...�,�,q,Q;PQ <br /> Printed Name; 1 ►Llah <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UPTO ONE HUNDRED THOUSAND DOLLARS <br /> (S10tl,0aa.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN 3ECTION 9708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (J <br /> (signatuna e10•57 licensed drtihotiaed repreaentativg), <br /> hernbyauthorize(print name <br /> ) Q1CtC PCCrn p� tiplxuti �f�tt �t h <br /> td 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 an the front page of this application. <br /> 8.29-02 1 MI <br /> EHD 29.02401 <br /> 6/'2!04 <br />