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San Joaquin County Environmental Health Department <br /> W�LL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> � v <br /> JOB ADDRESS: �j' 1/` t,(a��� � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapte 9 (commencing with Section 7000)of <br /> Division 3 of the California Business and P ssions Code andl my license is in full force and effect. <br /> Contractor Name: V&W D 'lling, Inc. <br /> License#: 72 904 , " Expiration Date: 4130/2022 <br /> Signature: �, Title: President <br /> I <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 /> EI provided for by Section 3700 of the Labor Code, for the Derformance 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#: 9115022-20 Exp. Date: 10/2/2022 <br /> I certify that in the performance of the work for whichthi em it is Issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' co pensation law of California, and agree that if I <br /> should become subject to wor 'compensation prov sions of Section 3700 of the Labor Code, I shall <br /> fo ,with comply with those provisions. <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 PERMIT APPLICATION <br /> I, Karli Renae Stroing ,hereby authorize L vim ' �/Ity <br /> d C- .—d Au a.e Rcp—nWn. pr nt rm o/AUN mt <br /> to sign this San Joaquin ounty Well rmg Permit Application on my behalf.I understand this <br /> authorization Is valid for one y ar la `ite to the work15111dalled on the front page of this application. <br /> n u� r n a <br /> EHE 29-01 6-23-2015 Site Mitigation well Permit Application <br /> I <br />