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F 06/28/2005 16:23 FAX 70737443 Woodward Drilling • Q002 <br /> 0,06 � <br /> o6 n <br /> San Joaquin County Environmental Health Deparhnent Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �` /� / / ` PERMIT SR#: <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. —f <br /> License#: - I )100 l1siI Expiration Date: 0 / <br /> Date: lL lol� Q CContractor: 1�� Q,rril (� 1 ) 1. YA <br /> / <br /> Signature: in n�_.�. (A /(����iir7n2p Title: Yr_ 1rT i <br /> Printed name: (( <br /> RKERS' 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 n ers are: t�� I l• <br /> Carriers . <br /> Tnrl / f IS l L 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: 104=5 Signature: C�/e�A� WOT9/ Il12Jt /�_ <br /> Printed Name: CC-Y 6 n!G <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 /> AUTHORIZATIONr FO,.IR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I ��nn••�Ll l l6 y) I,)a 1y] (slgnatur -67 1i sed au o zed representative), <br /> hereby authorize(print name <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand 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 /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 622/04 <br /> 06/28/2005 TUE 17:15 [TX/RX NO 64281 1I1002 <br />