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09/19/2681 09. 48 7073745577 WOODWARD DRILLING CO PAGE 03 <br /> 08115/2001 11'48 209-579-2222 "ODESTO ATC PAGE 83 <br /> T <br /> San JoaquIM County Environmental Health Sarv(c4t, Unit IV Well PermIt Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> k <br /> LICENSED CONTRACTORS DECLARATION (,LCD) <br /> I naraby of 'n 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 ftrtl forCe and effect. <br /> License 71 90� EXpirsuon Gate' 1 C] <br /> ! i <br /> Date "if ' Ol Contractor Woo 99 Ogl.Luara <br /> s(Snatt>Ir�' Title'd 771GW S eAAJ,4f.X4 <br /> Printsd name; 96"d&1C. 1aC.&Sroeo Al"N <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury ane of the (0110WIng declarations (CHECK ALL THAT APPLY) <br /> I have and Will maintain a certificate of consent to self insure for workers'co rip $anon. as provided for by <br /> S1 Section 3700 of the Labor Code, for the performance of the work for which this permR Is Issued <br /> I have and will rnainWn workers'Compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the worst for which this permit is rssued My workers'compensation Insurance <br /> calmer and policy numbers are <br /> Caniar: STA' _91JOVa FoRcyNumberi O <br /> I.certify that In the pwformance of the work for which this permit is issued, t shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of CS00MIa, and ear"that if i <br /> should become sutgect to the workers' aampan aallort provisions of Section 37DO of iiia Labor Code, t small <br /> fortftwdh comply with those provialms <br /> Date l "'��'0 I S(gnature• <br /> Printed Name, AS F1f=Q!t!j <br /> ' WARNING J=AILURS TO SECUFtE WORKERS' C00APENSAT10N COVeRAGE IS UNLAWFUL,AND SKALL SUBJECT I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AHO CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000),IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATI TOnNEY'S Z=EES,AND OAMAGES AS <br /> PROMED FOR IN$90TION 3706 OF THE LABOR CODE. , <br /> t, - 611!14 J1rdlC&$?'ielog" (C-57 licensed authartsadrepresentattvs), hereby <br /> autftorU* ara V eo-Sc -- <br /> to stars this Sart Joaquin County Woll Permit App€icelion on my behalf 1 understand this authart;atl*n Is valid for <br /> • air+(1)year and Is limited to the work plait datod on the front page of this application. <br /> SAZ:M I MI <br />