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05/ 24 / 2006 14 : 36 707374F577 WOODWARD DRILLT ` IG CO <br /> PAGE 02/ 05 <br /> 09 / 23 / 2000 TUE 17 : PT FAX f� 00a / 002 <br /> San Joaquin County Environmental HOOM Department Unlit IV Well Permit Application Supplement <br /> .JOB ADDRESS: q q © lam PERMIT SR#: O ( Z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am lice%ed Undor the provisions of Chapter 9 (commaneing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license Is In full force and effect <br /> License #: _7 / O D • 7 1 EXpiratlon Date: �_ I e, 7 <br /> Date: a � =2 �L( /6 6 Contractor. _ tjrDOr> cJ K 2n& Q ,p1� 2i c i u e- G <br /> Signature: (�: f r& Tine• <br /> Printed name: _ N r,, mo gw� 45 c�JUO' y <br /> WORKERS' COMPENSATION DECLARATION <br /> I 'hee y affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of cormQnt to 90MInsure for workers' compensation, as provided for <br /> by Section 9700 of the Labor Code, for the performbnce of the work for which this permit is issued. <br /> _ I have and will maintain workers' compensation insurance, as required by $ectjon 3700 of the Labor code, <br /> for the performance of the work for which this permit Is Issued_ My workers' compcnsation insurance <br /> carder and policy numbe: <br /> numbers ar <br /> be <br /> Carder: _ % Poliicyy Numbar: 0 ^r yyU" 2 d,72-,3,,L3 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any Parson in <br /> any manner so es to become subject to the workers' compensation laws of Callfamia, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 5700 of the Labor Code, I shall <br /> forthwith comply with those provision, <br /> Expiration Date: /A O (. Slgnaturg; �+ <br /> Printed Name; Co N r. <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINER UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNRY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION Ftft bME'R�'THAN C47 SIGNING PERMIT APPLICATION <br /> (signature ofCS7licensed autharked repmuentative), <br /> hereby nuthorlxo (/p/tint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf, I understand th19 AM1110fis9tien is valid for <br /> One (1) year and Is limited to the work plan dated on the front page of this appllaAtlen, . <br /> 8.29P02 / MI <br /> EHD 29-02401 <br /> 6/22/06 r <br />