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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1245 W. Charter Way, Stockton PERMIT SR# <br /> LICENSED iCONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licens d under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Busir ass and Professions Code and my license is in full force and effect. <br /> License#: C57-720904 Exp Date: 11/18/2013 <br /> Date: Contra tor: <br /> V&W Drilling <br /> Signature: Title: <br /> C-'hr ef <br /> Karli tro' <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will mainta'i 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 /> x <br /> I have and will maintair 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 Nu 9,026354-13 <br /> I certify that in the perfo mance of the work for which this p mit is issued, hall not empl y any <br /> person in any manner o as to become subject to the work s' compensati n law of Cal' ornia, <br /> and agree that if I shouli I become subject to workers' compens 'on provisio s of Section 700 of <br /> the Labor Code, I shall forthwith comply with those rovi ions qq 1 pp�� <br /> Exp. Date: 10/1/2014 Signature: <br /> Karli Stroin <br /> Print Name: <br /> WARNING:FAILURE TO SECURE VIZOR RS'C MPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND IVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DA AGES AS PROVID OR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZAT F R TI r C-57 SIGNING PERMIT APPLICATION <br /> Karli Stroin9 1; /(signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ota K4iaDD to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 un rsta this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of ti is application. <br /> WELL PERFAT APP <br /> EHD 2901 OWN112 <br />