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40s,? 1/ 5 Fib �,� — ro3 <br /> 10 <br /> 1 <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL. <br /> JOB ADDRESS: rf �J ( PERMIT SR A <br /> L 0& 34&3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Di Vision 3 of the Califomla Business and Professions Code and my license is in full force and eftecl. <br /> Lica+se++:_ 9©6$99 Expoate: 11/30/11 <br /> Date: fi/Fi/11 Conlraclor. PeneCore DdI in <br /> Signature: Ar— Title: CEO <br /> Print Name: TUa U en <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby afgrrn under penalty of perjury one of the following declarations:(check one) <br /> _I have and will maintain a oeAlflcala of twoont 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 /> 41 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 carrier and policy numbers are: <br /> Carrier: State Fund Polley Number: 0000 5943920 1 0 <br /> I Certify that In the performance of the wok for which(his 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, <br /> and agree that it I should become Subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code,I shell forthwlth comply with those provisions, <br /> Exp.Date: 811112 Signature: <br /> y J <br /> Print Name: Tuan Nouylen <br /> WARNING:FAILURE TO SECURE WORHLRW COMPENSATION COVERAGE 13 UNLAWFLIt,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRINNAL PENALTIES AND CIVIL FINES UP TO Stea,FW.IN ADDITION To THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES.ANO DAMAGES AS PROVIDED FOR IN SECTION 1708 OF THE LAWN CODE. <br /> AUTHO TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature of C-57 licensed authorized represenlatival, <br /> hereby authorl t r" name) SAiC ,to sign this San Joaquin County Wall & Boring Permit <br /> Application on my behalf. I understand this authorization IS valid for one year and is limited to the work <br /> plan dated on the from page of this application. <br />