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EHD 29-0t 07r2(VID SHELL PERWT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> JOB ADDRESS: _ 2 C !rt;.S y-e4 C ` S 3�, PERMIT SR# <br /> `-J <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provis,ors 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 /> License #_ �4 C1 Exp Date: O BL4 Z0l3 <br /> Da'e �I, 20�'l Contractor. PeY1-CC�,r f <br /> Sign 3lLre - Title: CEO <br /> Print Names Tl.ar. Nguyen <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and veil 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 /> hermit 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 insurarce carrier and policy numbers are. <br /> Carrier: State Fund Policy Number: l�,i41 -11 -nnnZ31 <br /> I certify that in the performance of the work for wnich 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 suolect to workers' compensation provisions f Sect on 3700 of the <br /> Labor Code, 1 shall forthwith comply with those provisions. <br /> Exp. Date: 8/1/12 Signature: <br /> TUan Nc� en <br /> Print Name: <br /> WA.RNIN( . FAILJRE TO SECURE WORKERS'COMPENSATION COVERAGE IS USILAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP 10 5100,000.IN ADDITION TO THE COST OF COMPENSATION,'NTERES-, <br /> AT'ORNEY S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37PS OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, [. (signature of C 57 licensed atrthorized representative), <br /> hereby authorize j nt name) �j(�r�(ji� _ , to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the .work pian dated on the front page of th!s application. <br />