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07/30/2001 09:37 7073745677 WOODWARD DRILLING CO PAGE 02 <br />A V :It@!P10 <br />San Joaquin County Environme tat ea th Services If'nit IV Well Permit Application suppl ween <br />i � �- PERMIT SR#: !� 2i <br />[! / <br />.30B ADDRESS:1T ` � � - <br />k <br />i <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />t.efrm that i am licensed under the provisions of Chapter,9 (commencing with Section 7000) of Division <br />i I f Fjby <br />the <br />the <br />' 3 of 6'usiness and Professions Code and my license is in full Torte and effect. <br />ExpirationD ' " <br />License #: `7 1 Li O % � -- Date: . <br />'30 o ( Contractor: WOO b w AI R_ <br />I / � <br />Signature: Title: <br />Printed name: o� G <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 />I Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />1'. . <br />_C I have and will maintain workers' oompensation insurance, as required by Section 3700 of the Labor Code, <br />I for the performance of the work for which this permit is issued. My workers' compensation insurance <br />li carrier and policy numbers are: <br />Policy Number: -2 °� 3 g <br />Carrier: y O <br />,. 7� D <br />I certify that in the performance of the work for which this permit is issued, I shall not employany person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />l should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall <br />forthwith comply with those provisions. <br />I; Date: '7 0f' Signature:�`–�— <br />i 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 />i ($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 />I d,� (signature ofC-57 licensed authorized representative), <br />nereby authorize (print name)_ <br />i <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 />5.17-20001 MI <br />