WP0043077 - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department CONTRACTOR AUTHORIZATION FORM JOB ADDRESS: 945 S. Ham Lane, Lodi, CA 95242 PERMIT WP #: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business anel-Professions Code and my license is in full force and effect. Contractor Name V&W Drillin License #: 720904 C-57 - Expiration Date: 4/30/202A4 Signature: Title: President/CEO Print Name: Karli R. Stroing Date: 3/11/22 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as L3 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: State Fund _ Policy #:_9115022-2 Exp. Date: _10/2/2022 I certify that in the performance of the work for which this per ' is issued, I shall not employ any person in any manner so as to become subject to the workers' compenqation law of California, and agree that if I should become subject to work co pensation provisions/,6f Section 3700 of the Labor Code, I shall Aorthwith comply with those provisions. Signature:L1 Print Name: Karli R. Stro WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, Karli R. Stroing ereby authorize (lace -Kuhl & Associates LlcensvA AulhvnxeA Repivsenlahvv rr Pnn1 Name 1 A;,1h. eC Agent to sign this San Joaquin County Well tk Boring Permit Application my behalf. I understand this authorization is valid for one�yepr an04 liyn d to a work plan date n the front page of this application.