Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 8010 S. Airport Way, Stockton, CA 9520(, <br />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 California Business and arofessions Code and my license is in full force and effect. <br />License #: <br />Date: 6: 231201 ; <br />Signature: <br />906899 <br />Tuan Nguyen <br />Print Name: <br />Exp Date: 11'30/2010 <br />Contractor: Penecort Drilling <br />Title: i'rc.iticnt <br />WORKERS' 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 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 />compensatiornl insurance carrier and policy numbers are: <br />Carrier: �N C��` (C� \���. �1 ���11�ClYlU� Policy Number: c�()U�D 05 G <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 subject to workers' compensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those provispns. <br />Exp. Date: 8 Signature: / <br />Print Name: Tuan Nguyen <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BJE 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 IZAT N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, - __�� / (signature of C-57 licensed authorized representative), <br />he e ( nt n e) C ri Dr an t to sign this San Joaquin County Well & Boring Permit <br />Application on y behalf. I d t�nd tis authorization is valid for one year and is limited to the work <br />plan dated on the front page is application. <br />FHD2901 <br />'flE" F�RPrl' App <br />