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59 7073745677 <br />69/2 I VV'., 13:49 FAN 925 6024720 <br />%3''I28aa 15:21 20946834.12 <br />WOOD,JARD DRILLING CO <br />t?'I'ir; F.NGINi,Fl?ING (NC -4Woodward <br />FIFTH FLOOR <br />PAGE 02 <br />DriIIin 2003 <br />PAGE 03 <br />f —3an Joaquin County En ,rranrn,nto Health Services, Unit IV 1Naf( Permit Application msnt <br />b <br />.308 ADDRESS'�Si~� PIl=RMIT SRI#: � <br />v25�� <br />LICENSCD CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7400) of Division <br />o° ;ha Business and Professions Code and my license Is !n full force and effect. <br />License #: J10 U 7 � __ Expiration Date: 7 - S I - a i <br />Date: CO) ontractor: L_j Oo t3 W A Z (, (3 P_ i L L t ry C_ _.. <br />Signature; Title: <br />Printed name" �fft'1K �r�5$i%'(ti"'7 <br />WORKERS' COMPENSATION DECLARATION <br />Hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificata of consent to self-insurs for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this perml`. is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. <br />for the performance of tho work for which this permit is issued. My workers' compensation insurance <br />carrler and policy numbers are: <br />Carrion: 04 Policy Number: 00,2,023B____�__,^ <br />i <br />� — {certify that in the performance of the work for which this permit is issued, I shall not omplay any person �n <br />any manner so as (v Uzuu-tj out lck:t to the, workers' compensation laws of Catifomia, and agree that if I <br />should become subject to the worker's' compensation provisions of Section 3700 of the !Labor Code, I shall <br />forthwlth comply with those provisions, <br />f <br />mate: 3 "2't ` L7 I ---signature: � <br />Printed Name: -- <br />WARNING; FAILURE TO SECURE WORKERS' COMPSNSATION COVERAGA9 13 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />{a1Q4,400.i, 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 />—(signature ofC-57_6"nsed authorized representative), <br />nemby authorize (print name) Mv�-��� �i�� S 8-�— ✓ eS�v� <br />this San Joaquin County Well Permit Application on my behalf. 1 understand this authorizatlon is valid for <br />'ehL: 1Y)`year antJ is limit4dA0 this work plant dated on thr., front page of this application. <br />.1".0. ,,,,.,. ,r.. <br />