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Apr-10-02. 11 :34A VIRONEX, INC. 510 568 7679 P.02 <br /> APP-10-200= :2'2 uj00DLjAPD-�-'LYDE CONSULTANT dY4 ,:ebb <br /> r . <br /> sir;Joaquin County Environmental Health Services,Unk FVWell Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> lI <br /> LICENSED CONTRACTORS DECLARATION LCD ! <br /> I hereby affirm that I•am kweed under the provisions of Chapter 9(comms efrig with Section 7000)of Oivisior <br /> 3 of:me Business and Professions Code and my Iieense is in lull force and effect. � <br /> License Expiration Data, I �_ LC%� <br /> Date: `} 1 l� ��3 Contractor: V U 0.�2 C , ..y-n L- <br /> Signature: t` - :\:��LX'�C'. 4lam- Titlt 'JI I )�' <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATIOW ! <br /> I hereby affirm under penalty of perjury one of thefcllowing dederaGons: (GHICK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation.as provided lar DY <br /> Sic'.?nn 1700 nr the Lat or Code, for the WOrrlanCe Of the work for which this permit is issued. <br /> �I Have and will maintain workers' compensaWn insurance,as required by Section 3700 of the Labor Code, <br /> j rnr the nno,..r-v4mce r the work for which this permit is issued. My urorkem'compensstion insurance } <br /> ::ar.i +' ii•.y n Jf Uc�s are: <br /> Policy Number: - <br /> , <br /> 16ertlf,(Viet in the performance of the work for which this permit is issued, I shills not employ any person in <br /> +ry mann<^r s❑as In ha-ame subject to the workers'compensation laws of Catifom:a, and agree that if I <br /> sl)o;.'d becorn C;ubjeH.to the wo*ers'compensation provisions of Section 3700 of the Labor Code,I shall 1 <br /> f3101w-0l!OM01y with those provisions, <br /> Signature:_ <br /> Printed Nance,-71 <br /> +f` a <br /> ' <br /> WARNING:FAILURE TO SECURE WORKE"I COMPENSATION COVERAGG I$UpiLAWFUl. AND SHALL SUSJECT <br /> AN FNIPIOYER TO'CRIMINAL M ALTIESAND CIVIL FINES UP TO ON!RUNORM THOUSAND DOLLARS <br /> Ili A0017!ON TO THE COST OF COMPENSATION.INTEREST.AWORNErS FEES,AND DAMAGES A,R ! <br /> ro.1 Jii SrCTi%)N 1706 Or t'HE LABOR CODE. <br /> WC-57 licensed aumorned ropresemative", <br /> J hentbya�etharlte(ptititr+amol r�' ��1`� {-�4�V�t!{ r' � ( CJti`�G� �� <br /> to sign thins San Jaaggiii County Well Permit Application on my bahaM. I understand this aulhorizatlon is valid for <br /> one(1) the work pian doted an the front page Of this application. <br /> 5-1.7-200p f MI I <br /> TOTRL P.©3 <br />