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San.Joaquin Courity Environniental Health Department <br /> VVEi-L & BORING PERMIT APPLICATION' SUPPLF-ME14TAL <br /> SOB ADDRESS: 11 00 N Furry 'aad,Lad CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LLD) <br /> I hereby affirm that I am licensed tinder the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: 7110079 Exp Date: 7-31-2015 <br /> Date: Contractor: Woodward Drilling <br /> Signature: 007�f 0-X-P , 4-PZI( Title:�. ,ea <br /> Print Name: or, 1 o <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 <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> x I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued, My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: <br /> NY Marine&General Insuarnca Policy Number: WC 201300004258 <br /> --- <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10-1-2014 - - Signature: (' !/1P r o �?- b <br /> Print Name: (No(�: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNILAIAIFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC i I0N 3706 OF THE-LABOR.CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 —SIGNING PERMIT APPLICATION <br /> (signature of 0-57 licensed authorized representative), <br /> hereby authorize (print nan-Ie) Fraderick A Yukic to sign this San Joaquin County k�lell & Goring Permit <br /> Application on my behalf. I undersLand this authorization is i.aiid for one year and is limited to the work <br /> plan dated on the front pag e of this application. <br /> AHD 28.07 D�lOc/1'' N'ELL PERt•a7 APP <br />