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Apr-10-02 11 :34A VIRONEX, INC. 510 568 76179 P.02 <br /> APR-1@-'2002 u100Di'W.D-CLr'DE CONSUL7PNT ,S bb N•U-i tis <br /> s ' . Si r,Joaquin County Envirom ental Health Services,Unit fV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: ; <br /> i <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affrrrn that I am licer+sed under the provisions of Chapter 9(Commencing with Sec'.lon 7000)of Oivi2iOr <br /> 13 of'me.Business and Professions Code and my linense is in full force and effect. <br /> License ft; i j Cl ,Expiration Date: <br /> Mote: `} t 1 O ��aContractor: V 0 t1,-Z- C <br /> Signature: C��s --' 1C� Titter C� = ')` CA <br /> \J <br /> me►_ ( ��\�t4 <br /> Printed na <br /> WORKE1RV COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing dedare6onv: 101110K ALL THAT APPLY) <br /> I <br /> I hav•e and will maintain a certificate of consent to calf-inswe for workers'compensation.as provided for by <br /> ^' 1700 of It+e Labor Code,for the performance of tha work for which this permit is issued. <br /> -S,,/I have ll maintain workers' compCnsatlon insurance,as required by flection 3700 of Ule Labor Code, <br /> j ror rhE r. .r;,r^ience ar the work for which this permit is issued. rely workers'compensetiotl insurance <br /> Policy Number. <br /> 16erWy Piz#in the performance of the work for which this poral;t is issued, I shelf nut employ any person in <br /> Dry rnann<r.,-n as In hn-orne sub,ect to the workers'compenaatfon laws of CaliCom:a,and agree theft if <br /> ( sl=o 'd becorng;ubjert to the workers'carrmpertsvitien provisions of Section 3700 of the labor Code. I shell f <br /> f0101, 11h COmaly with those provisions. I <br /> nal9: ' 0 1 0 Signature: _ �� ��. �_-' J l 'k— <br /> Printed Name:_ ���« r? U—k-\ � <br /> i i <br /> i <br /> WARNING:FAILURE TO SECURE WORKERS,CoMpENSATION COVERAGE 15 WiLAWFUL,.AND SHALL SlJt'3.fECT <br /> AN FMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINt'.S UP TO ONE HUNDRED TNOUSANb DOLLARS <br /> 111+.AOL:IMN t'O THE COST OF COMPENSATION,INTEREST.ATTORNH1f•S FEES,AND DAMAGES A$ I <br /> ttj SECTION z7os vE YHI:LABOR CODE. <br /> __.„(slgnaRure ofrC•S7 ticensed authorized ret6rtsenlative;, <br /> hereby buthorize(print"3M*l jn Kl`) t IG i <br /> to sign ahia San,loaquiii County well Permit Application on my behalf. I understand!his euthorizatlon is valid for <br /> yearantl is;t,rnl"Olo the work pian dated on the front Paye of this applloattor.. <br /> 1 s-f7-zoao t ull i <br /> TOTPL P.03 <br />