Laserfiche WebLink
07/30/2001 09:37 7073745677 WOODWARD DRILLING CO PAGE 02 <br />ifr no <br />Sart Joaquin Coun Environmental Health Services, unit IV wen trermii MIJP6-'Mgw„ <br />/ PERMIT SR#: W 2 Od <br />JOB ADDRESS: / 0 3 4�4 <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 #:1 / <br />p '7 Expiration Date: 0 Z'" <br />o f Contractor. ` W oo b w A R. -Z fl oe-r e -e -e e0G d-0-, <br />Date: <br />Signature: 'rn-r� •'" �� <br />Title: / T <br />l� <br />Printed name: Gi o <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 tabor 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: „ <br />Few L D 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 Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: <br />rf o D/ Signature: <br />Printed Name: o i✓ /�' LtJO oda <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) <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 />J-, r -cvv I_ <br />