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Wr�ut <br /> 09/19/200I 09 48 707374567 2` IVDE3T[)OODWARD DRILLING CO rA1C PAGE 03 <br /> FiH%1.51200} 11,'c(Q _209-5199 L1..� � <br /> r <br /> Son,loaqurn County P-r;. nmarIt&I Haatth Swvkss.Unit 1V Wolf Permit Appitcation Supplement <br /> JOB AQDR '55: `{ / �;4 PERMIT SFtIP: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby 8ffirm that i am licensed under the Provisions of Chapter a (cornmancing with Section 7000)Of DIVSSiom <br /> 3 of the Sustrisss and p fesslons Code and my license is In fult force and effeoL <br /> QWCV Exphtion taete <br /> License d <br /> ' <br /> Date 01- �s"Q� Contractor <br /> Title: 7X.*1% 9AN 9- <br /> glgnature: ' <br /> Printrd n>}tne: <br /> WORKERS' COMPENSATION OF-CLARATION ' <br /> I hereby affirm tinder penalty of pglury one of the following declarations (CHECK ALL THAT APPLY) <br /> rovided <br /> r,r,i have and w+'iE main#ain a certsl�r.fee��$�crman�sent to f-fture for o the work for ���s,IsssRed for by <br /> Serction 3700 of�e Labor God P <br /> I have and will maintain workers' <br /> farowt��chnth�soperm�t s issued cb- as r 1VSy worlcere`cxtmpeSection 70ns insuran 0 of the Labora ode. <br /> � far the pCrforrna�rfca Q tt't <br /> carrier and Policy numbers are <br /> G�irrisr: <br /> ori ye policy Number. <br /> 1 Orly <br /> manner so as to y that of the p borMgncq of the work ecame subject to thefworkers,compensation taws of Callfomia,and agree ttfet if I in <br /> �,y m <br /> at+auld l,ecoma subject to provisions <br /> Compsn3atlon provisions of SecOan 3700 of the Labor Code, I st► <br /> aA <br /> forthwith comply with those <br /> signature 24. yalai� <br /> Printed Nanne' Iii. re Acb 04.1 <br /> GE 13 UNLAWFUL,AND SKALL <br /> AN 15 11biG FAILURE PJM NAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 7 4O SAND DOLLARS 8JEC7 � <br /> AN EMP0),(N D C 1 <br /> (3iO4,t)Oa),iN ADDITION TO <br /> 370 01:THE LABOR CODS Crf,fNTERES7�oiTdRNI:Y'S >`Ei~8, AND DAMAGES AS <br /> PROVIDED FOA IN SkC7l <br /> (C-67114anspd authorized r*plVg%ntadyo),hereby <br /> laden tl+1s Smn aoaquin County Well Permit,Appliaatlon en my behalf i understand this suthariz:tion is valid for <br /> i one(i)year arnd is limited to the work plan datod on the front q*"Of this spPllestien, <br /> �.47.�00o r viii <br />