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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 4 <br /> JOB ADDRESS: L' `fir ce�— <br /> PERMIT SR fit: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I air licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Caiifomia Business and Professions Code and my license is In full force and effect <br /> Contractor Name V & W Onllinw, Inc. <br /> 1 <br /> License 20 Expiration Date 4/30/2020 <br /> - -- — - --- <br /> Signature � ^..�u Title. Presided <br /> Print Name Karii Renae Stroing Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I ;iereby affirm under penalty of perjury one of the following declarations (check one) <br /> I have and will maintain a cenificate of consent to setf-insure for workers' compensation as <br /> Provided for by Section 3700 of the Labof Code, for the performance of the work for which this <br /> permit is 1ssu-ed <br /> have and will maintain workers' ccrn'oensamn insurance as required by Section 3700 of the <br /> Labof Code, for the pelormance of the work for which this permit is issued. My workers' <br /> ,ompertsation insurance carrier and policy numbers are. <br /> Carrier: State Fund Policy #: 9115022-18 Exp. Date: 10,'2,12019 <br /> I certify that ;n the performance of the work tCf which this ermit is issued, I shall not employ any person n <br /> any manner so as to become subject toe wrkers com nsatron law of Caiifomia. and agree that .f I <br /> should become subs t to wor)(ers' compWisatiol provlslo s of Section 3700 of the Labor Code I shall <br /> / forthwith 001 with tho provisions <br /> Signature f'. 0 <br /> — <br /> Pr nt Narne Karn Renae Stroing -- <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3746 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C -SIGNING PERMIT APPLICATION <br /> I, Karli Renae Stroing her by authorize <br /> :. Md we4.+rrrrrtar.w ._ .w. .Af.-:••nwa R,yen <br /> i <br /> to sign this San Joaquin Cou y We11 I!< B Ing unit plication on my behalf. t understand this <br /> authorization Is valid for one ear nd i im' ed o the or an dat on the front page of this application. <br /> r ''t <br /> EHO F-2_23-201= S!e T,A!-aa,,:;r•Vie:' Parm_t <br />