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04/19/2005 09: 51 FAX 70737443 Woodward Drilling la002 <br /> 04/19/2005 10:00 FAX 209 94808 ` U002 <br /> Nom"" <br /> San Joaquin County Environmental Health Department Unit N Well PermitApplic tion Supplement <br /> JOB ADDRESS:17 Y x' if� 6s'd'�` IlaERMIT SR#: y 3 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 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 /> License ft:�f d O { � Expiradon Date: <br /> Date: al I q Contractor:lN GC.J��'.� -b <br /> Signature: .Printedname: Cdlo6lwd WIdb ttI <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: -S /PTz�- F-111Vn Policy Number: <br /> I 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, 1 shall <br /> forthwith comply with those provisions. <br /> Expiration Date: �S� Signature: <br /> Printed Name; <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 /> ($700,000.),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ,2 9 (eignaturoaoo(C-57 tic n eedd�a orlmd representative). <br /> hereby authorize(p nt name)--IF <br /> to sign this San Joaquin County wall Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is Ilmlted to the work plan dated on the frond page of this applloauon. <br /> 8.29-02/MI <br /> EHD 29-02-001 <br /> 6112/04 <br /> 04/19/2005 TUI 10: 44 [TX/IU NO 53091 U002 <br />