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04/19/2005 09:51. FAX 7073744300 Woodward Drilling Ia002 <br />04/19/2005 10:00 FAX 209 948081 Z002 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Applic tion Supplement <br />JOB ADDRESS:%/AK-d'PERM17 SR#: <br />LICENSED CONTRACTORS DECLARATION LCD <br />I 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 #: v� f / Expiration Date: -%701— <br />Date: <br />W/ —Contractor Z <br />Signature: <br />Printed name: CD/JG/N� (rt%d D t�tJr4tie�p <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declar4lons: (CHECK ONE) <br />_ 1 have and will maintain a certificate of consent to eelf4risure for workers' compensation, as provided for <br />by 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 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�/3� Tom^ FIVA.)IJ Policy Number: d 0 D 3 $ <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 />forthwith comply with those provisions• <br />Expiration Date: � �`� Signature: <br />Printed Name <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 F=EES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature ofC-S7 licensed authorized representative), <br />hereby authorize (p(/It name) 416 <br />to sign this San Joaquin County wall 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 />8-29421 MI <br />EHD 29-02-001 <br />6/12/04 <br />04/19/2005 TUE 10:44 [TX/RX NO 53091 0 002 <br />