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10/14/1999 13:44 7073745677 WOODWARD DRILLING CO PAGE 02 <br /> 10-12-1999 10: 16A?A FRU P. 2 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: JAZ{c1 f r f 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 Division <br /> 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License V O Q-1 Expiration Date: Of <br /> Date- /f/2� � Contractor. OU G�/� G�rG GO <br /> SignaturiR' itle: <br /> Printed name: © C /N L i CU.0j)w f}R <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _1 have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br /> ection 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> have and will maintain workers'Compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work fog which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. F9EMoPJ-% e__pm P o>,) Policy Number: 56 SO —0/5 cj—_7 7 FDV <br /> I certify that in the performance of the work for which this permit is issued, 1 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 /> Date: Z 1 9: Signature: t� a <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE_ <br /> i <br /> I, (C-57 licensed authorized reprsaentative),hereby <br /> authorize <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 limited to the work plan dated on the front page of thio apVication. <br />