Laserfiche WebLink
San Joaquin County Environ mi antal Health Department <br /> °rrVELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 11200 f I Furry Road,Loda,CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chanter 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#: 7110070 Exp Date: 7-31-2015 <br /> Date: C 1 Contractor: Woodward Drilling <br /> Signature: J G. b2g1 , , �_ _ Title: ` dea <br /> Print Name:—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 wort: 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: NY Marine&General InsuarnPolicy ANumber:o� WC 201300004258 <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: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAIAIF ,AND SHELL SUBJECT AN EMPLOYER TO <br /> CRWA AAL 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 Irk SECTION 370G OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGHING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorPze{print narrlel Fraderick A Yukic to sign >hls San Joaquin County trVell & Coring Permit <br /> Application on my behalf. I understand this aul.horizatian is valid for one year and is limited to the work <br /> pian dated on the front pige of this application. <br /> 8HD 29.01 05108/12 V''EL-PER6':T APP <br />