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11/08/'2005 22: 05 5105687679 VIRONEX PA=GE 033 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �' l{i. PERMIT <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 <br /> /^feeffect. <br /> License#:�0 Expiration Date: v 5 ' "'M ' Q_� <br /> Date: W C011 • OS Contractor. <br /> Signature: Title: Ce <br /> Printed name: (\ CA <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 f tate 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: I� � t Policy NumbEr: c (5l 3 O <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 cf Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. I� <br /> Expiration Date: rJ(O' 05- (XPSignature: O <br /> Printed Name: o, Dam anfi' <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYE=R 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 /> AUTHOR.IZ ION FOR OThIER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' - (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) I wc� t re ',�wks <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valld 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 /> EHD 29.02-001 <br /> 6/22/0d <br />