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0 0 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: East Charter way PERMIT SR#: S'L� CLEF <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> 710079 712009 <br /> License#: Expiration Date: <br /> Date: <br /> 6/23/2008 Contractor: Woodward Driling Co., Inc <br /> Signature: Title: President <br /> Printed name: Concing E.Woodward <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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> /I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: State Fund 20238 <br /> Policy Number. <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: y0Z r d t Signature: <br /> Printed Name:Concing E Woodwa <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTHORIZATION�FOR <br /> , OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1• - ti Awl+--; �' �`--'/ (signature ofC37 licensed authorized representative), <br /> hereby authorize(print name)Chris Huang/Susan Lowe <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 undeP§tand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 6.29-02/MI <br /> LH1t S7-024))I <br /> r+l1'-AW <br />