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San Joaquin County Environmental Health Department <br /> WELL He BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2315 N. El Dorado St, Stkn, CA 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 licens iis7s/Iinn 711 force and effect. <br /> License#: C57-720904 Exp Date: ' <br /> Date: I Contractor: v&W Drilling <br /> Signature: Title: <br /> Karli �tr�j <br /> Print Name: <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 /> compensa' insuran arrier and policy numbers are: <br /> Gamier: Policy Number: <br /> 90a (,.173T�-�✓ <br /> I certify that in the performance of the work for which this permit is issue hall not emplo any <br /> person in any manner so as to become subject to the workers' com ensati n law of C Iforn' , <br /> and agree that if I should become subject to workers' compensation &ovisio s of Secti 3700 f <br /> the Labor ff ode, I 1hall forthwith comply with those provisions. r <br /> Exp. Date: Signature: <br /> Print Name: rb <br /> WARNING:FAITO CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN OYER TO <br /> C INAL PE LTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> A TORNEY'S F ES,AND AMA ES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> OWAT� // -F€� OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> herebyauthQonehalf. <br /> Raynold Kablanow <br /> t nam , to sign this San Joaquin County Well & Boring Permit <br /> Application 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 05/09/12 WELL PERMIT APP <br />