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JOB ADDRESS: Vpp/-fodryc' Al PERMIT SR#: <br /> CEN ( C� <br /> LI �ED <br /> G�ONTRACTORS DECLARATION <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 /> Contractor Name: V & W Drilling, I <br /> License#: 720904 Expiration Date: 4/30/2020 <br /> • � l <br /> Signature: 411, jtv Title: President \ <br /> Print Name: Karli Renae Stroing Date: <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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: State Fund Policy#: 9115022-19 Exp. Date: 10/2/2020 <br /> 1 certify that in the performance of thew r which this permit is issued, I shall not employ any person in <br /> any manner so as to become subjec to the workers' compensation law of California, and agree that if I <br /> should become subject to workers' mpe.sation pro Islons of Section 3700 of the Labor Code, I shall <br /> forth ith comply withfhose provisions. <br /> Signature: 4AVo <br /> Print Name: Karli 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 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PER T APPLICATION <br /> t Karli Renae Stroing , her <br /> e authorize %'V, k <br /> I - <br /> Name of C37 Llcenae0 Aulnonmo Rep.—tauve / ptlnl Name of ulAona Agent <br /> to sign this San Joaquin County W II 8e B ring Permit A41ication on my behalf. I understand this <br /> authorization is valid for on y r a d ii mit, o the work pl n dated on the front page of this application. <br /> t , <br /> lanatun o en d t on t Repm mauve <br /> \ <br /> \7 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />