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lot <br /> _ D�_f ?�it <br /> San JoaquIn County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I I W ( PFRMIT SR d <br /> LICENSED CONTRACTORS DECLARATION iLCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Ca!ifoma Business and Professions Code and my license is in full force and effect. <br /> License#: 906899 Exp Date: 11/30111 <br /> Date: 9/15/11 Contractor= -p-evie Czre--- <br /> Siqnature: . -�: - - Title:— CEO <br /> mi <br /> PrintNae- Tuan u e�n <br /> Id'VORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations- (check one) <br /> I have and will maintain a certificate of consent to self-insure for %vorkers* compensation. as <br /> provided for by Section 3700 of the Labor Code. for the performance of the work for which this <br /> pertnit 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 carrier and policy numbers are: <br /> Carrier. State Fu nd Policy Number. 0004439-09 <br /> I 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, <br /> and agree that if I should become sub)ect to workers* compensation provisions of Section 3700 of <br /> the Labor Code, I shall for"-nvith comply with those provisions <br /> Exp. Date: 8/1/11 Signature: <br /> Print Name: Tuan Ngfjyen <br /> fAMLURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SnALL SuajECT AN EMPLOYER TO <br /> CFUN04AL PENALT)ES AND CML FINES UP TO S10,0,000, IN ADDMON TO THE COST OF COMPFNSATION. '%TFREST. <br /> ATKJW1IlEY'SFE".AND DAMAGES AS PROVIDED FOR IN SECTION 37Ci,6 OF THE t ABOR CODE <br /> AUTHOFZIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L (signature of C-57 licensed authorized representative), <br /> hereb4luthori4print name) ANIS CI to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to ;he ,York <br /> plan dated on the front page of this applicati <br /> 002" t—-t_lv r VIP <br />