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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Ll4{,�1,4.,49�.V' -r�e►.(rr "Ax, PERMIT CA PERMIT SR ;; 00630 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing .%ith Section 7000)of <br /> Division 3 of the Califemia Business and Professions Code and my license is in full force and effect. <br /> License :f 906899 Exp Date: _ 11/30/11 <br /> Date: 8131/11 —Contractor. QQV�2 ll'e_ <br /> Signature Tide: CEO <br /> PnniName: TUan NCILIVerl <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following declarations: (check one) <br /> _ I have and vill 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. I <br /> ! X 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 carrier and policy numbers are: <br /> Carrier. State Fund Policy Number: 541 -0000731 -11 <br /> 1 certify that in the performance of the work forwhich 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, <br /> and agree that if I should become subject to workers'compensation provisic-s of Section 3700 of <br /> the Labor Code. I-shall forthwith comply with those pro,isicns <br /> Exp.Date: 8/1/12 Signature: <br /> Print Name: Uan NgUyell <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL RHES UP TO $100,000, W ADDITION TO THE COST OF COMPENSATION. WTEREST, <br /> ATTORNEYS FEES.AND DAMAGES AS PROVIDED FOR Oct SECTION 3706 OF THE LABOR CODE. <br /> AUTHO lZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I• S.a�gnU <br /> ur0 of C-57 licensed authorized representaUvel, <br /> hereb authorize not name) ARIA t is San Joaquin County WIell & Boring Permit <br /> Application on my behalf. I understandis authorization is valid for one year and is limited to the -vork <br /> plan dated on the front page of this application. <br /> aoz<.: : . <br />