Laserfiche WebLink
:-1/191/2001 09 48 7073745677 WOODWARD DRILLING CO PAGE 13 <br /> 08115I2i lkVD2-9T0 RTC <br /> µ PAGE 03 <br /> San Joaquin County>5-nvironrnentat Health Servlces,Unit IV W011 Permit Application Suppiemant ` <br /> JOB ADDRSSS: 43X1, 6-Yca •' 4 � +ut PERMIT SR#: <br /> LIMNSED CONTRACTORS DECLARATION (CD) <br /> i <br /> r <br /> I nereby affirm that I sett 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 futi force and effect <br /> 1 License _ ` Expiration Data <br /> Date.,_ Cb»traGtor l/�i <br /> Signature' Title, OJ! .. Vev%J S-Ir7AA1_ --4& &- <br /> Prtnted name; e-A&�' teat.5sr.� <br /> WORKERS COMPS SATION oi~CLA RAT1Qk , <br /> f hereby affirm under penalty of perjury one of the following deeiaretiona (CHECK{ALL THAT APPLY) <br /> I have and w1l maintain a cettAr ate of consent to self-i=,re for workers'compensation, as provided for by <br /> Secticlri 3700 of the Labor Code, for the performance of the warts for which this permit to Issued <br /> I have and writ maintain workers'compensation insurance, as required by Section 3700 of the tabor Code, <br /> for the performance of the work for which this permit Is issued My workers'compensation tnisurance <br /> carrier and policy numbers are. <br /> Carrier; 15-rAr6 rzvyu4 Folley dumber: - <br /> �,�,,,I certify that in the performance of the work for which this permit is issued, I shall not employ arty person in <br /> any manner so as to become subject to the workers'compensation taws of Cailfomla, and agree that if i ; <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cade, I shalt <br /> forthwith comply with those Provisions <br /> Date Signature ' <br /> Printed Name' s i-RO0,-7 <br /> WARNING. FAILURE TO SECURE WORKERS'COMPENSATION G0VER4Gtx 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CPJMtNAL PSNALTIES ANO CIVIL FIN93 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> tS1100,00a), IN ADDITION TO THE COST OF COMPENSATION,lNnREST,,53TORNEY'5 FeES, AND OAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, r <br /> t, !C/A (C•57 licensed autharfaad represuntative),hereby <br /> autho <br /> AL I <br />. to stgR this Sam Joaquin County Well Permit Application on my behalf i tinderastand this authorization to valid for <br /> one(1)year and Is Limited to the work plan dated on the front page of this application. <br /> 5-37.2000/MI <br />