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Sam Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ' I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> jLicense#: 906899 Exp Date: 11/31./2011 <br /> Date: 12/10/09 _ contractor: PeneCore Drilling _ <br /> Signaturw itle: CEO <br /> Print Na Tuan N en <br /> � Y <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> X_I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit Is issued. My workers' <br /> compensation Insurance Carrie.and policy numbers are: <br /> Carrier: State Fund Policy Number: 05943909 <br /> l certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 8/31/2010 Signature: <br /> Print Name: 4u/an N Lyuyen ' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOR A ION FO OT R THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ? I / (signature of C-57 licensed authorized representative), <br /> he tty uthorize iprin 0 me) an-y Flora _ ,tD <br /> sign;?Joaquin San Joaquin unty Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81291021MI <br /> I <br /> GND 20,0i llMDr VA't i.FEfiM,i A9c <br /> i <br /> i <br />