Laserfiche WebLink
07/30/2001 09:37 <br />JAVII-IWO <br />7073745677 <br />WOODWARD DRILLING CO <br />PAGE 02 <br />San Joaquin County. Environmental Health Services, Unit Iv wen rerm" r,IJPI-c �V41 ��rr�•• •- <br />iOB ADDRESS: G+rJ 04 PERMIT SR#: 021-M3 <br />LICENSED CONTRACTORS DECLARATION (LCD,) <br />hereby 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 />License #: <br />r7 1,O Expiration Date: <br />Date: 3 a ° { Contractor: W oo V w A, R- <br />Signature: <br />D, Title: r/ D�� <br />Printed name: _ C,— <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the fallowing 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 />C I 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 />Carrier: S iT <br />Policy Number: <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 Labot'Code, I shall <br />forthwith comply with those provisions. <br />Date; r713 Signature: <br />I <br />Printed Name: L✓D on u--, 1n -- <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 />($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) 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 />r — nnAn P RAI <br />