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Apr-10-02 11 :34A VIRONEX, INC. 510 568 7679 P.02 <br /> APP.--10-2002 _2'23 u100DWW.D-CL'(DE CONSUt_TPNT 5:U t:IY4 S�bb W,Uj.ii'a <br /> ..• �..•.• r►tut tl0 <br /> n . <br /> Joaquin County Envirom ental Health Services.Unit rV Well Permit Application Supplement <br /> JOB AUDRESS: PERMIT SRO: j <br /> ' II <br /> LICENSED CONTRACTORS DECLARATION LCD ! <br /> i I hereby affirm that i am ftweed under the provisions of Chapter 9(coolr mneneng with Section ?000)of Oivisitm <br /> 3 of Ilia Business and Professions Code and my license is in full force and effect. i <br /> Licanse#: ( i C� r� Expiration Dots; i� %ti Q C:& <br /> DDte. Contractor: <br /> Signature: t er \r. _ Title: C� L17 i <br /> Printet3 name: <br /> WORKERV COMPENSATION DECLARATION <br /> I hereby 7ffirm under penalty of perjury one of thefolfowing dedarellons: (CHECK ALL THAT APPLY) <br /> I <br /> I have and will ma;m,3in a certificate of consent to self-inswe for workers'compensation.as provided for by <br /> ^'Sec:'nr,X700 of the Later Code, for the performance Of MR work for which this permit is issued. <br /> �1 have and will maintain workers' compensation insurance,as required by Section:1700 of the Labor Code, <br /> car thg r•n.o,q-tan(,e or the work fvrwhicft this permit is issued. My workers'compensetion insurance } <br /> .,171yp)(7 tiers are: <br /> j Ca.rtsr: ��S t Citi', CA- j1� Polley Number: <br /> I cer*(t11zt in the performance of the work for which this permit it;issued, I shall not employ any person in <br /> +ry m?nnzr so a�fn h+;mrne subject to the workers'compensation laws of California, and agree that if <br /> simu'd becom c subject to the workers'carnpensetien provisions of SeCtlon 3700 of the labor Code, I shall f <br /> f0101-0 V)moiv with those provisions. I <br /> Signature:_ <br /> Printed Name, <br /> WARN1,40_FASLURE To SECUREWORKE",COMPENSATION COVERACE M WiLAWFUt,AND SFIALL Sll19JECT <br /> AN EMPLOYER TO'CRiM1NAL PENALT1ESAND CML FINES UP TO ONE MUNORM THOUSAND DOLLARS <br /> I. G0,000.),R?AD LTiTION'r0 THE COST OF COMPENSATION,INTEREST.ArMRNE r'S FEES,AND DAMAGES AS I <br /> rort)t;SrCrION?706 Or YHE LABOR CODE. <br /> „ (signature o}C•37 Ifcerosd authorized rsp►esernative), <br /> hcritby authorize <br /> to S19M IN&San Joageairi County Well Permit Application on my berialf. I understand this 0u1horlZation is valid for <br /> one 0)yrearsntl¢s:1%mlW'10 the work pian dated on the front page of this application. <br /> 5.1.7n201101 ffil i <br /> r i <br /> Z. <br /> �.. <br /> TOTS P.03 <br />