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JOB ADDRESS: Ips/fmar—1 "�ac PERMIT SR #: <br /> CE � c( t ( <br /> LIN � <br /> ED 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 /> Signature: U I 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 /> 13 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 /> 4� 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' mpertsation prq Isions of Section 3700 of the Labor Code, I shall <br /> forth ith comply withose provisions. <br /> f <br /> Signature: <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 PERNUT APPLICATION <br /> 1, Karli Renae Stroing ,he authorize 411,4c, <br /> /I AV i" t kc <br /> Nama of C-57 U—Seo Autnortad Reprasentatrve Print Nama of Autf,onx Agam <br /> to sign this San Joaquin County W II& B ring Permit A lication on my behalf. I understand this <br /> authorization is valid for on ylr a d i mi ed o th�work pin dated on the front page of this application. <br /> C� <br /> r � <br /> ignatun o m a onU Ropn ntmu <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br /> I <br /> I <br />