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JOB ADDRESS: <br />0 0 <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />8010 S. Airport Way, Stockton, CA 95206 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 Professions Code and my license is in full force and effect. <br />License #: <br />906899 <br />Date: 7/1/2014 Contractor: <br />Signature: Title: <br />Tuan Nguyen <br />Print N e: <br />Exp Date: 11/30/2016 <br />Penecore Drilling <br />President <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 />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: 4� 4:,V(n 1��-•KCAn(D. C k Policy Number: WNO !&�6` 0 Lck <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' guanNguyTen <br />ovisions of Section 3700 of <br />the Labor Code. I shall forthwith comply with those pr <br />Exp. Date: `6 i` Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT 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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I Tuan Nguyen <br />hereby authorize (print name) Luis Mercado <br />(signature of C-57 licensed authorized representative), <br />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 the work <br />plan dated on the front page of this application. <br />EHD 29-01 05/09/' <br />