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11-03-2000 09:32RM FROM TO 19258339548 P.03 <br /> San Joaquin County Environmental Health Services, Unit IV Well permit Application Supplement <br /> JOB ADDRESS: Frewert Road, Lathrop 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#: e,77- 70,rlf Expiration Date: <br /> Date: 11-3-00 Contractor: Pacific Drilling <br /> Signatu Title: Owner <br /> Printed name: Al Donahue <br /> WORKERS' COMPENSATION 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 workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> XX I have and will maintain workers' compensation insurance, as 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 /> Carrier: 6/nprrzh vol t6wi eh Zrv5'.6VA'e, Policy Number: Z OS7o?7(n /5703 0 <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 California, and agree that if I <br /> should become subject to the workers' compensation vi ions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: _ <br /> Printed Name: AL anahuG <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 /> 1, Al Donahue <br /> (C-57 licensed authvrizetl representative),hereby <br /> authorize Robert D. Campbell <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 this application. <br /> I <br /> i <br /> �I <br /> i <br /> ` <br /> TOTAL P.03 <br />