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' Apr-10-02 11 :34A VIRONEX, INC. 510 568 7679 P.02 <br /> APR-10-2002 =2'? u100DA;P1)-CLYDE CONSUL7PNT 51L1 1-f(4 :�bJ <br /> n <br /> Sari Joaquin County Environmental Health Services.Unit IV Well penult Application Suppletoent <br /> JOB AUDRESS: PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am kersed unser the provisions of Chapter 9(commenC;ng with Section .7000)of 0 Vi4ior <br /> 3 of:me Business and Pntfessions Cods and my license is in full force and effect. <br /> License#: ( i C� `� Expiration Date: <br /> D:*te: �} ` 1 O ��a /C�ontraeber• ,V, 1•� {�� r�v2�C �''�(' <br /> Signature: <br /> Title: Cdi <br /> )t' <br /> Printed nam e: <br /> j� WORKERS' COMPENSATION DECLARATION <br /> I I hereby affirm under penalty of perjury one of the following declareCons: (CHNOK ALL THAT APPLY) <br /> I have and will ma%Main a certificate of consent to self-insure for workers compensation.as proviced far by <br /> i ^'';��'.'nr 1700 of the L'obcr Dade, for the performanCB of th9 work Nr which this pern'i!is issu8d. <br /> 1 ZI Have and will maintain workers' corn pt rtsetlon insurance,as required by Section:'1700 of tMe Labor Code. <br /> f rnr the or the work for which this permit is issued. My workers'compensation insurance <br /> C arras r. LI t Cir' Ca 1�'1 pokey Numbtr <br /> i I certfFy Met in the performance of the work for which this permit is issued, i shelf not employ any person in <br /> +ry manner sn as in hercirne sub,,nt to the workers'Compensation Paws of Cafifomia, and agree that if <br /> jshou'd be'orn C;ubjer.•t to the workers'compersatien provisions of Section 3700 of the Labor Code, I shell t <br /> fW0h ;lhlIcomply with these provisions. I <br /> +� nata: i �L�-- Signature:_ 1��I��'kA� <br /> Printed Narne; <br /> WARNNG:FAILURE TO SECURE WORKERS,COMPENSATION COVICRAGG iS UhLAWPUL.AND SMALL SUBJECT <br /> AN FMPLOYER TO'CRIMiNAL PENALTIES AND CIViL FINES UP TO ONE HUNDRED T14OUSANb DOLLARS <br /> f$105,000.),IN ADuiTION TO THE COST OF COMPENSATION.INTEREST.ATTORNErS FEES,AND DAMAGES A,5 t <br /> ?::•C,v:;;F r,=ort!i+Sr, Tt-nN?7oe 1OK-tNE LABOR CODE. <br /> I � .,M(sigeature 0C•571lcensed autborlxed representative!, <br /> J hentvyatiethorise(printnamei _2�K1 <br /> to sign this Sa'r Joagtriii County Well Permit Application on my behalf. I understand this outhorlxation is valid for <br /> one(T)yearsn,o i-% the work pian dated on the trent page of thts application. <br /> s•17•znaa r ertr i <br /> TOTAL P. <br />