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f f 07/30/20i1l- 09:37 7073745677 WOODWARD DRILLING CO PAGE 02 <br />Roil- 14 7- c c - <br />Sart Joaquin County Environmental Health Se ces, Unit IV Well Permit nyR1waLw�� <br />4&0&4 �" PERMIT SR#: �D' <br />JOB ADDRESS:_ �� �- C%"�""" ��f�--- AW q <br />LICENSED CONTRACTORS DECLARATION (LCD,) <br />!lhsreby 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 />Expiration Date: r7 /.D; 1: - I <br />License #: ri I <br />3 p o { Contractor: Woo b A, R -.D J) R-, � <br />re -.0 <br />Date: <br />. Title: <br />Signature: <br />d <br />Printed name: d^� <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 />li _XI 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 />51� <br />Carrier: � <br />W D Policy Number: <br />1 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 />i should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br />forthwith comply with those provisions, <br />dZo I Signature: _ ?' �-�'i•�-r1- <br />Printed Name: C QWARNING: FAILURE 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 />(signature ofC-57 licensed authorized representative) <br />hereby authorize (print name) <br />L <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 />T <br />