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SanJoaquin County Environmental Health Department <br /> WELL& ORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1245 W. Charter Way, Stockton <br /> PERIn1T SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am license J under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Busin ss and Professions Code and my license Is in full force and effect. <br /> License 41 C57-720904 <br /> Exp Date: 1I3n1 !� <br /> ZV <br /> Date: Contra tor: V&W Drilling <br /> Signature: Title: C`--` <br /> Print Name: Karli StrOi <br /> WORKERS'COMPENSATION DECLARATIDN <br /> I hereby affirm under penalty of pe jury one of the following declarations: (check one) <br /> I have and will maintain i certificate of consent to self-Insure for workers' compensation, as <br /> provided for by Section 3 00 of the Labor Cade, for the performance of the work for which this <br /> permit is issued. <br /> X <br /> I have and will maintain v orkers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the perk rmance of the work for which this permit is issued. My workers' <br /> compensation insurance ca rrier and policy numbers ares <br /> Carrier: State Fund Policy Nu 9,026354-13 <br /> 1 certify that in the perform nce of the work for which this p mit is issued, hall.not empl y any — <br /> person In any manner so E Is to become subject to the work s' compensaIt n law of Calornia, <br /> and agree that if I should become subject to workers'op pens on provisio s of Section 700 of <br /> the Labor Code,I shall forth ith comply with those rovi ions. <br /> Exp.Date: 10/1/2014 Signature: <br /> Print Name: Karii. Strain <br /> WARNING:FAILURE TO SECURE WORKERS'C MPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES�pNo CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AN �DAMAG AS PROVIO OR IN SECTION 3705 OF THE LABOR CODE, <br /> Pi1dTHORtZP F9ER'1TFt C-57 SIGNING PERMIT APPLICATION <br /> Karii Stroin '� <br /> 1. � UtA (signature of C•57 licensed authorized representative), <br /> hereby authorize(print name) x °o1 K I"°° ; to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I I rst n 4his authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this a plication. <br /> EHD29-01 05109112 <br /> WELLPEWITAPP <br />