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Apr-10-02 11 : 34A VIRONEX, INC . 510 568 7679 P.02 <br /> AP'P-1J-2130-2 ^-2!27- CONSUL`,-�NT VJ <br /> . n <br /> ' Sar;Jcaquin County Envlronntental Health Services,Unh IV Well permit Application Supplement { <br /> JOB ADDRESS: PERMIT SRO: M; <br /> II <br /> LICENSED CONTRACTORS DECLARATION LCD } <br /> I hereby affirm that I am{+versed under the provisions of Chapter 9(t ornmenoinp with Section ?C00)of Division <br /> 3 ofme ousiness and PrnfeSSions Code and my license is in fall force and effect. I <br /> C- I <br /> Linense#: j i - a -r E <br /> xpiration Date: <br /> Contractor: <br /> Signature: i1,X\C� _ Title <br /> Printed name_ <br /> f <br /> WORKERV COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following deolarations: (CHgCK ALL THAT APPLY) <br /> I have and will maintain a at:rtift@*S of consent to self-insure for wGrkers'compensation.as provided far t,y <br /> nr fhe L;5Ccr Code, for the performance if tha work for which this perrrA is issued. <br /> i i I <br /> end will rr,a,ntarn workers' compensation insurance,as required by Section x700 of the Labor Coda, , <br /> Jnr the r , r^i�nce o'the worn for vihici,!this permit is issued. tity arorkers'compensation insuTence } <br /> 17:'y,11)(71)(.,Sare: f <br /> i Car0-r: �J t Policy Number: "- <br /> 4 I tic,t thzt in t`,e?erformance of the work forwhich this pormit it isBUGd, !shelf not employ any person in <br /> pry m-n::er,,)a�-to hinmme sub;ect to the worke•s'compersabon!aws of California, and agree that if <br /> ' slmu'd hecorn c 3uhjcrt to the,workers'enmpensatien provisions Of Section 3700 of the Labor Code, I shall t <br /> a-)mOly with those provisions. I <br /> r � <br /> k nate: ' ,` _' �'- Signature: �� <br /> Printed Name; <br /> WARNING_FAILURE TO SECVRE WORKER",COMPENSATION CLCVERAGE IS UNLAWFUL,AND SHALL SMECT <br /> MI FMDLOYER TO CRIMINAL PEFiALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANb DOLLARS <br /> f t�1 Q01,000.),11{Ap 01710N TO T-1E COST OF COMPENSATION,INTEREST,AYTORNErS FEES,AND 0"AGES AS 1 <br /> MNignarture aflC•57 Ilcer3ed authorized represemative), <br /> I C <br /> to sign This San Joaquin County Willi Permit Application on my behalf. I understand this aulhorlrstlon is valid for <br /> one(1,)yearana ra kmitPp30 the work plan doted an the front page of this application.. <br /> � 5.1T-Z�0p 1 MII I <br /> --s 1 <br /> TOTAL ?,p3 <br />