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03 / 20 / 2001 10 : 00 707374567.7 WOODWARD DRILLINGC0PAGE 03 <br /> Y.. San Joaquin County Env iron�Health Services , Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : It 53 0 I PERMIT SR#: bOZS��u _ <br /> LICENSED CONTRACTORS DECLARATION (LLD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 ) of pivls,nr. <br /> 3 of the Business and Professions Code and my license is in full force and effect . <br /> License n' 710e�I ? 41 Expiration Datw 7 rS 1 - _ <br /> Date: . ^ zo - CJI Contractor 1 0,11, LI <br /> Signature: �_ Title: &E9#q7/ o#JSfa7A" Gew <br /> Printed name . lie 40046g�557"Ap* r7 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations : (CHECK ALL THAT APPLY) <br /> I have and wili maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 $700 of the Labor Coca <br /> for the performance of the work for which this permit Is issued . My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: �$ TAre rcyN6 Polloy Number, 662rooz 116 <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 9Ubject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provlslons of Section 3700 of the Labor Code, I she!; <br /> i forthwith comply with those provisions , <br /> I ? <br /> Date : J " ZO - (yL. Signature: , l _... <br /> Printed Name: & A< A i rAp ev? <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 /> (51002000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> iPROVIDED FOR IN SECTION 3706 OF THE L"OR COOS. <br /> �Jsned) Nl (C-57 sCansod authorized representstiva), haraby <br /> authorize :TF A W hlE � O rvr8g%r <br /> to sign this San Joaquin County well permit Application on my behalf- I understand this authorization is valid f:r <br /> one (1 ) year ana Is limited to the work plan dated on the front page of this application. <br /> £ 1 3CVd DIV WSIOL1W GZZZ - 64g-60L <br />