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03/30/2007 16:38 7073745677 WOODWARD DRILLING CO PAGE 02/02 <br /> Mar. 30. 2007 3: 39PM AT( '?.OUP SERVICES INC. No. 0169 P. <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 32 E4,4 HL.-/ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divlslon <br /> 3 of the Business and Professions Code and my license Is In full force and effect. <br /> License#. -7 <br /> 1007 9 Expiration Date: 07 <br /> Date: 0 3 0 —6 7 Contractor:_i()ayP W14-i`--b LAR-1 Com- Ce,-f.4-P1 A1Y ,-UC, <br /> Signature: Title' &£f/QRy1- <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by 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 3700 of the Labor Code, <br /> for the perforn mnoe of the work for which this permit is issued, My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: Rollcy Number: Qcla— bb 2-o L3 9 <br /> I 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 subject to the workers' compensation laws of California,and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: t0 —Zca-7 Signature: L�r72�r 4�' �Jo <br /> Printed Name: -Co-A1r21yC— r-, (AA c)Da'.a'/9!fQ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (4100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, <br /> /AUTHORIZATION FOR O H THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature oIC47 licensed authorized reprrsentative), <br /> hereby authorize(print name) �I� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is Ilmlted to the work plan dated on the front page of this application. <br /> 8-29.021 MI <br /> Stns 29.02.001 <br /> #Ln)ma <br />