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Expiration Date: 4/30/2022 <br />Date: 9)1.1-1 (9- I <br />Title: President , <br />San Joa uin County Environmental Health Department <br />WELL & BO • ING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: N . ky)1(,) PERMIT SR #: <br />' LICENSED ØONTRACTORS DECLARATION <br />I hereby affirm that I am licensed und r 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, lp <br />License #: 720 04 <br />Signature: <br />Print Name: Karli Renae Stroing <br />WORKER• ' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury me 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 work <br />Labor Code, for the performa <br />compensation insurance carr <br />Carrier: State Fund <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject Lo the orkers' comperation law of California, and agree that if I <br />should become subject to w ers' comp *ion provisions f Section 3700 of the Labor Code, I shall <br />forth ith omply with those p ovisions. <br />Signature: <br />Print Name: Karli Renae Stroing <br />WARNING: FAILURE TO SECURE WOR <ERS' 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 SECTI N 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICA ION <br />Karli Renae Stroing <br />Name at C-57 bcensed Authonzed Representative <br />i <br />herebmiutliorize <br />nt Name union <br />to sign this San Joaquin County W II Boring Petim it Application on my alf. I understand this <br />authorization is valid for on ar a d is ted to the orli(plan dated on the fro t page of this application. <br />eva urejof c'en Rep e ta e <br />rs' compensation insurance, as required by Section 3700 of the <br />ice of the work for which this permit is issued. My workers' <br />er and policy numbers are: <br />Policy #: 9115022-20 Exp. Date: 10/2/2021 <br />\ <br />EHD 29-01 6-23-2015 Site Mitigation Wet Permit Application