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09/19/20e1 09:48 <br />OF3/15/2E101 11:49 <br />707374E677 <br />2n-579 -2225 <br />WOODWARD DRILLING CO <br />MODESTO ATC <br />PAGE 03 <br />PAGE OS <br />n San Joaquin County Environmental Heahh Services, Unit IV Well Permit Application Supplement <br />ERMIT SR#: DOolcv <br />Signature: <br />Printed name. 6-ie4'et• eraeSS FAD re-\ <br />WORKERS' COMPENSATION DECLARATION <br />, t hereby affirm under penalty of Perjury one of the following leclaratIons: (CHECK ALL THAT APPLY) <br />I flata arid 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 Qf the work for which this permit Is Is5ue(1, <br />4.I have and wfil maintain woricers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the perforrnanos of the work for which this perrnit is issued, My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: Policy Number; CP:20Z.6 2 3 "l'AT'e‘ fyy•)1:1 <br />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' COrnpenSation laws of California, and agree that if i <br />should become subject to the workers compenStston provisions of Section 3700 Of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Oats: ?-/B-01 Signature: <br />Printed Name: ex/x.. ic-,24€4.5 Fear, <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 />(S100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, A.TTORNEY'S FEES, AND CAMAGES AS <br />PROVIDED FOR IN 3ECTION 5705 05 THE LASOR CODE. <br />roes5r#0470.1 (C-7 licensed atrthortzed representative), hereby <br />authorill @ et) CAPP-) V CEtle-S6 <br />to sign this San Joaquin County W*11 PermIt ApplIc.stion on my behalf. I understand this authorization Is valid for <br />an* (1) ysar and is limited to the work plan datod on the front page of this application, <br />11.2tQ!Mi <br />JOB ADDRESS; 093 <br />LICENSED CONTRACTORSS DECLARATION (LCD) <br />I nereby <br />afrni that I am licensed under the provisionsof Chapter 9 (comrnenoing with Section 7000) of Division <br />3 of the Business and Professions Code and my ticense is in full force and effect <br />License #. ,..C5_52_____LL.(2-0791 Expiration Date: 7- 31 -1,002- A ty i <br />Cate: - Ot Contractor: W0121)14)140f) 012-11.1...itOG <br />Title: (27215_,, AAJAile•