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EH02901 07!20.'10 WELL PERMIT APV <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 502 East Ciraw Linc Road 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 710079 Exp Date: -'J - l3 <br /> Date: Q-o`L- 1'21. Contractor: Woodward Drilling ('o., Inc. <br /> Signature: Titlea�_ . <br /> Print Name: <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 work for which this <br /> permit is issued. <br /> 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: Scabriaht Insurance _ Policy Number: BB 1113886 <br /> 1 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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code. I shall forthwith comply with those provisions. <br /> Exp. Date: 101111 _ Signature: (t���.W � L }tg{o�r,►na <br /> Print Name: _� <br /> WARNING r FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100.000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST. <br /> ATTORNEY'S rECS,AND DAMAGES AS PROVIDED FOR IN SECTION 1706 OF THE I ABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, l+ F I 'YWy - ,yt.eln.l) (signature of C-57 licensed authorized representative), <br /> hereby authori (print name) Brian Eyteheson. Parsons_ to <br /> sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHe TbL� a117P'�n <br /> ref <br />