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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Manteca, CA V _ PERMIT <br /> LICENSED CONTRACTORS 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 Califomia Business and Professions Code and my license is in full force and effect <br /> Contractor Name: V& W DHIli c. <br /> License # 720 04 -- - - - <br /> -- __ Expiration Date: 4/30/2020 <br /> Signature rale: Preside t <br /> _ .._ <br /> Print Name: Karn Renae Stroi Date. Lv <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 /> 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 /> 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#: 9115022-18 _ Exp. Date: 10/2/2019 <br /> I certify that in the performance of the r which this permit is issued, I shall not employ any person in <br /> any manner so as to become subje to th�ap <br /> ork 'compensation law of Califomla, and agree that if 1 <br /> should become subject to workers' peo p visions of Section 3700 of the Labor Code, I shall <br /> fort th cl wi those provisions. <br /> r <br /> Signature. <br /> Print Name Karli Renae Stroin <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 ,h y a orize Condor Earth Technologies <br /> to sign this San Joaquin Co ty Well oring P rmlt I tlo on my behalf.1 understand this <br /> authorization Ia valid for one y r d N d to the ork plan a on the front page of this application. <br /> t <br /> EHD 29.01 8-23-2015 Sae M.ft qaton We!'PA,mi'Acp.c4-on, <br />