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f <br /> Apr-10-02 11 :34A VIRONEX, INC. 510 568 7679 P.02 <br /> APR-10-^(Y:= 2'2 ul00DWW.D- L'r'DE CONSULTANT S_F+ t�'r'4 JL�b N.0.a-Uld <br /> r <br /> - Sari Joaquin County Eavkenrnantai Health Services.Unit W Weil Permit Application Supplement <br /> JOB ADDRESS: PERM T SRO: <br /> II <br /> LICENSED CONTRACTORS DECLARATION LCD ! <br /> I hereby affirm that I am iicer'+sed under the provisions of Chapter 9(comrnencfnp with Section .7000)or Oivisiar <br /> 1 3 of;me Business and PrCdMior>s Code and my license is in full force and effect. i <br /> UrAnse#: i C; CA Expiration Date; <br /> Dote: `} 1 p O Contractor: V C) <br /> SlUnature: C� . :�L.���l\t� Title: <br /> Printetj nam•: i (�\ 1 <br /> r— D <br /> WORKERW COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the faftwing declarations: (CHECK ALL THAT APPLY) <br /> I <br /> I have and will mai�lain a certificate of consent to self-insure for workers'compensation.as provided far by <br /> 3700 of the Lobcr Code,for the WormanCE a the work for which this permit is issued. <br /> �I have and will maintain workers' cornptrlsatlon insurance,as required by Section 3700 of the Labor Code, <br /> rnr the r +r r^�snce of the work for which this permit is isSued. My a crkeW compensslon insurance <br /> li:'y`)1)f71.)CfS are: <br /> i Ga.rssr: U t i C�YL Q G1- i Policy Number, - , <br /> i <br /> M I ccrHFr thz!in the performance ol the work for which this p4vmi't is issued, I Ghali not employ any person in <br /> cry manner so as In h#c,orne subject to dee workers'cornpensebon laws of Catiiforni, and agree that if 1 <br /> shOu'd becom a;ubjert to the workers'campertsatien pro'risions of Section 3700 of the Labor Code, I shell t <br /> farl',w,;1hlIaxttply with those provisions, j <br /> Signature:_ <br /> Printed Name:__ 1 <<1- (s � <br /> WARNINGI:FAILURE TO SECVREWORKE"I COMPENSATION COVERAGE ISUkLAWPUL„AND SHALL SUBJECT <br /> AN FMPLOYER TO CRIMINAL M ALT1ES ARID CIVIL FINES UP TO ONE HUNDRED TNOUSAND DOLLARS <br /> rfloa.troo.),I'+.A00MON TO THE COST OF COMPENSATION,INTEREST.AT'11ORNE r'S FEES,AND OA 4AGES A;; i <br /> rvrl!i+SCCT)tIN»06OF'i'Nlr LABOR CODE. <br /> f --(signature allC•57 Ikersed autnomtw rspresertrativerl, <br /> hereby authorize!Print riarnoL_._ 1 K1`.� t �G l/Vl�� ,,, ^ C Uti YC 01 <br /> V-- <br /> 149 si3O this San Joagttirl County Won Permit Appileation on my behalf. I undorstand!hls sulhorl=tlon is valid for <br /> one(1)year.antl is:1%n It"lo the work pian dated on thefrenr page etthts application. <br /> 5-17-2Gtio f MI i <br /> TO A- P.03 <br />