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10/11/2005 15: 41 7073745677 WOODWARD DRILLING CO PAGE 02102 <br /> UC,1 . 11.2910S 2:20PM APEX ENVIROTECH,INC. 140.693 P.2 <br /> `W, NOVO, <br /> San Joaquin County Environmental Hoolth Department Unit IV Wall Permit Application Supplement <br /> 1 <br /> JOB A13DRESS: 64q I PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION CD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(comfnencing with Sedan 7000)of Division <br /> 3 of the Business and Professions Code and my license Is in full force and aftcL <br /> a � <br /> License 1`k; '7 O D7 R „Expiration Date: Lo 7 <br /> Date: , Contractor & JOG O W&Q-.Q J12-f l--UA_ 4 <br /> Signature ��� Title: <br /> /�i2.t3 1 <br /> Printed name: JN(/i�+ Q a D W Pq &J1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the follawing declarations: (CHECK ONE) <br /> I have and will maintain a ca ificate of consent to calf-insure for workers'Compensation.as provided for <br /> by Section Mod the labor Code,for the performance of the work for which this permit is issued, <br /> -Y—Ni have and will maintain workers'compensatlon insurance,as required by Sedan 3700 of the Labor Cade, <br /> for the performance of the work for which this permit In issued. MY workers'compensation Insurance <br /> carrier and policy numbers are; <br /> Carrier: _ 4T�f7�T� r=N/l/.Q Policy Number: <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 Callfomia, and agree that if I <br /> should becorrle aubject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature:_ <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKBRR'COMPENSATION COVERAGE It UNLAWFUL,AND SHALL SUBJECT <br /> ANEMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND AOLLARS <br /> 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 OTH R THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signeturo ofC-57 licensed authorized raprasentative), <br /> hereby authorize(prinwarne) -'( <br /> to algn this San Joaquln County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and is Ilmitcd to the work plan dated on the front pass of this appiloatlon. <br /> 8-29-021 Ml <br /> axD 211-02-001 <br /> 6122/04 <br />