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03/06/2001 16:44 7073745r77 WOODWARD DRILLIh'^CO <br /> PAGE 02 <br /> ?3/ 6/2001 15:55 209468 `"r° FTH FLOQR PAGE 02 <br /> Ban Joaquin County Environmental Health Services, Unlit IV Well Permit Application Supplement <br /> JOB ADDRESS. o( �. PERMIT SR#. 00, j l/ <br /> LICENSED CONTRACTORS DECLARATION ( D) <br /> i <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 100D)of Division <br /> 3 of the Business and Professions Codes and my license is in full force and effect, <br /> License#: .r ;7/400 79 �Expiration pate: <br /> Date: _' f , , _Contractor dtt' .+f? �G�i�✓ <br /> Signature• Title:_4pwndr-r-e eg'F F"� <br /> i?rinted haul!: �✓ +r�s� mss/ <br /> WORKERS' COMPENSATION DECLARATION . <br /> I heareeby affirm und6r penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> f I have and will maintain a certificate of consent to self-insure for workor9' compensation,as provides for py <br /> .�.. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Coce:, <br /> for the performance of the work for which this permit is issued. My workers'Compensation insurance <br /> carrier and policy numbers are: <br /> r <br /> Carrier. „ ,� d/r✓• _- _M policy Number: _ <br /> I certify that in the petformance of the work for which this permit is issued, I shell not employ any person in <br /> any manner so as to become subWt to the workers'compensation laws of California, and agree that if f <br /> should bo wrne subject to the workers'compensation provisions of Section 3700 of the Labor Cade, I shall <br /> fbrtthwith comply with those provisions. i <br /> Date: .- r Signature: <br /> ' / <br /> . ted a <br /> Pr rt �,�-�rr�-rt?r�t�/��� - <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 /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATtORNEY'S FEES,AND DAMAGES AS E <br /> PROVIDED FOR IN SECTION 3706 OP THE LABOR CODE. <br /> i <br /> I, r 'gnature ctC-5T licensed authorized representative), <br /> i hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit ApplIcation on my behalf. I undorstand this authorization Is valid for <br /> one(1)year and is tirneited to the work plan dated on the front page of this mpplleation.. <br /> i <br /> i 5.17-20001 MI i <br />