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03/06/2001 16:44 7073745677 WOODWARD DRILLING CO PAGE 02 <br />:.3/CS/2001 15;55 2094683433 FIFTH FLOOR PAGE 02 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />ic <br />�.J A D ESS: Off • % /�� _ � PERMIT SR#: Lo <br />;ED CONTRACTORS DECLARATION (LgQ-) <br />i <br />1 hbreby affirm that I am licensed under the provisions of Chapter 9 (oemmencing urith Sdation 7000) ofeDi\risior3 <br />,,i 3 _Qf the Business and Professions Code and my license is in full force and effect. <br />License #: r Expiration pate: Z -,o l <br />Date: - Contractor: <br />X ! Signature -,A <br />Printed name: <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 />1 have and will maintain workers'. compensation insurance, as required by Section 3700 of the Labor Goan, <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. �G21,( Zvi ✓� -� Policy Number: Q T r� <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 provisions of Section 3700 of the Labor Code, I shall <br />forthwithcomplywith those provisions. <br />`Date:~rD __ Signature: <br />WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SU JE T <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5140,OpiJ.), 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 />!��'�► ignature ofC-57 licensed authorized representative), <br />hereby authorize (print name) ZzZtE�— �. ----- ' <br />I 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 />5-17-20001 MI <br />