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••• <br /> 04010:03610ty:enccirosoriental',Realtit Sfervices;'Llnit-At <br />„ <br />:.4161thlitirifiE613 ;! t <br />OirttOtAPPItC..g..100 i0;111)Ple71'„ e,.rirrf :;-••• ::,•• • . . . . , •• . , <br />07/17/2001 15:12 70737'1 5677 <br /> WOODWARD DRIL TNG CO <br /> <br />PAGE 02 . <br />05/15/2000 OU:21 209460433 <br /> FIFTH FLOOR <br /> PAGE 03 <br />LICENSED CONTRACTORS DECLARATION (LQ1;) <br />I <br />hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br /> Expifetion Date: <br />ntractor. W00 R <br />Title:Orif ‘44770#____Paldue'l Cd <br />EX faiC557-0)"1 <br />WORKRS' COMPENSATION DECLARATION <br />lorrr.MAN <br />I hereby affirm under penalty of perjury one of ti-m folloviIng declarations: (CHECK ALL THAT APPLY) <br />carrier: ...52(6,,TA_Etze2L), Policy Number: <br />. I have and will maintain workers' compenseton insurance, as required by Section 3700 of the Labor Code, <br />I have and Will maintain a certificate of consent to self-Insure for workers' cornpansation, as prOVided far by <br />StOtOri 3700 <br />of the Labor Code for the performance of the work for which this permit is issued. <br />for the performance of the work for which this permit is issued. My workers' compensation Insuranoe <br />wrier and policy numbers are: <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 3100 of the Labor Code, I shalt <br />fortWth comply with those provisions. <br />„nature; 44 aka IY-• <br /> <br />ozic,03s <br />Printed Name; <br />WARNING <br />FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, A.ND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND chill PINES UP TO ON 6 HUNDRED YHOUsAND DOLLARS <br />($100,0011). IN ADDITION TO THE COST OF COMPENSATION, INTEREST. ATTORNFf'S reEs, AND DAMAGES Ag <br />PROVIDED FOR IN SECTION 3106 OF THE, LABOR CODE. <br />eeloit seOeSS-7;e4D &.1 <br />authorize a."7"7",r.1.-1C.Cit <br />to sign this San Joaquin Count/ Well Permit Application on my ballet. I understand this authorization is valid for <br />one (1) oar andIs linilfad to the °Iwo an dated the frontyaoe of this aoplicatiOn. <br />Ze 3nVci JI7V0 ON sniimis 2099t9eEG :17T T5OZ/ZIa0 <br />License it: '70011 <br />Date: -I? <br />Signature: <br />Printed name: <br />Date: <br />(C-S7 licensed authorized representative), hereby