Laserfiche WebLink
41 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: <br /> PERMIT SR #: <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 California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V & W Drilling, Inc. <br /> License#:A720�04 / Expiration Date: 4/30/2020 <br /> Signature: ' Title: Preside t <br /> Print Nameing Dater , <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 #: 9115022-19 Exp. Date: 10/2/2020 <br /> 1 certify that in the performance of the work fwhich this permit is issued, I shall not employ any person in <br /> any manner so as to becom-- subject to theworkers' compensation law of California. and agree that if I <br /> should become subject to wotkers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Karli Renae S oing <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 /> 9 I <br /> 1, Karli Renae Stroing hereby m, ice a+:�thorize' <br /> Naof C 57 Ld Authorized Repr ntatry ,' (L) t Namc( 1/I Audtoriz gent <br /> to sign this San Joaquin C unty Well & Boring�Permit Application on mbehalf. I understand this <br /> authorization is valid for one a and - li i ed to the wor plan dated on the front page of this application. <br /> / <br /> Signa, rc 57 L msc Au ed Repr en Wtive <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />