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10/14/1999 13:44 7073745677 WOODWARD DRILLING CO PAGE 02 <br /> 10-12-1999 10. 16A?A FRO► P. 2 <br /> San Joaquin County Environmental Health Servicoc,Unit IV Wali Permit Application Supplement <br /> JOB ADDRESS: .�-q 9 I f r _ 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# f 0 01 Expiration Date: "7101 <br /> Date /��Cj �j Contractor I t)0007 Gc//911� GZrG e—Z A)C- GO A , <br /> Signaturo: �Title: <br /> Printed name: C aJ w 1q 1�e <br /> WORKERS'COMPENSAT1Old DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workars'compensation,as provided for by <br /> ection 3700 of the Labor Code, for tho performance of the work for which this permit is issued. <br /> Z, <br /> have and will maintain workers'compensation insurance,03 required by Section 3700 of the Labor Code <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Merrier. �?�o►�i �G•n 01.8ia W D),)_Policy Number: 5'C SO --0 J 5`7-7 7 E t <br /> I certify that in the performance of the work for which this permit is issued, l 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. 1 <br /> Date: l� /Z q:3 Signature- `_ _ G.�J <br /> Printed Name: cajakD <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 /> (4100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIUBD FOR 1N SECTION 3706 OF THE LABOR CODE_ <br /> i <br /> (C-57 licensed authorizod reproccntctivc),hereby <br /> authorize caw k f <br /> to sign thio San Joaquin County Well Permit Application on my bohatf. I undoMtnnd this authorization is valid for <br /> one 1 ear and is limited to the work plan dated on the front page of this application. <br />