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0 , <br /> Sin Joaquin County Environmental Health Departrnent <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1245 IN . Charter Way, Stockton <br /> PERMIT SR# <br /> LICENSE CONTRACTORS DEECLARATION (LCD) <br /> I hereby affirm that I am licei sed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California But flness and Professions Code and my license is in full force and effect. <br /> License#: C57-720904 Exp Date: ' OTS 1 I3'b1261 L <br /> Date: Contra tor: V&W Drilling <br /> Signature: Title: <br /> Print Name: Karli t i <br /> RKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty oi perjury one of the following declarations: (check one) <br /> _I have and will mainh in a certificate of consent to self-Insure for workers' compensation, as <br /> provided for by Sectior 3700 of the Labor Code, for the performance of the work for which this <br /> permit Is issued. <br /> X <br /> _I have and will mainta i workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the I sr-formance of the work for which this permit Is Issued. My workers' <br /> compensation insuranc I carrier and policy numbers are; <br /> Carrier: State Fu id 9,026354-13 <br /> Policy Nu <br /> I certify that in the pert mance of the work for which this p mit is issued, hall not empl y any <br /> person in any manner o as to become subject to the work s' compensate n law of Cal'cmia, <br /> and agree that If I shout become subject to workers'compens an provisio s of Section 700 of <br /> the Labor Code, I shall forthwith comply with those rovi ions <br /> Exp. Date: 10/1/2014 Signature: <br /> Print Name: Karli Stroin <br /> WARNING;FAILURE TO SECUREV�yI0RK RS'C MPENSATION COVERAGE IB UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES NO IVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,ANaaJJ GES 11S PROVIO OR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZAT F R THERIT C-57 SIGNING PERMIT APPLICATION <br /> Karli ,Stroing U /(signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) R1f' old K Ian to sign this San Joaquin County Well 81 Boring Permit <br /> Application on my behalf. I tin rstan this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of th application. <br /> END 2801 05109112 <br /> WELLPERMITAPP <br />