Laserfiche WebLink
PAGE 05 <br />PAGC 83 <br />WOODWARD DRILLING CO <br /> <br />0S/13/213.01 09: 48 7073745677 <br /> <br />_06/J5/2001 ill 4a 78-579-.5 %LEVI') ATC <br />j San Joaquin County Environmental —Health ServiCele, Unit IV Well Permit Application Supplement <br />I, JOB ADDRESS: PERMIT SRS: 640 545 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm ffiet I am licensed under the provision-S.0f Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license Is in full force end effect <br />44 7X7 .. Expiration Cate: <br />Date: 9 - 16-al contractor: .,(...)poilwiteo <br />SIgnature: L2c2 Title: 77(2.__AL_____1§-I S P/AAJ.144.4pe- <br />Printed name: eteix. Paiessreo <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the follcrwing declarations: (CHECK ALL THAT APPLY) <br />I <br /> <br />have and 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 of the work for which this permit is Issued, <br />6. I have and will maintain workers' compensatbn insurance, as required by Section 3700 of the Labor Code, <br />far the performance of the work for which this permit is issued. My workers' compensation ineLirance <br />carrier and policy numbers are: <br />Carrier: 5rAorc tJ,SJC Policy Number; CIO ZO 2 3 Ea.? <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' cornpenseon provisions of Section 3700 Of the Labor Code, I sheil <br />forthwith comply with those provisions <br />Date: T-i8 -0( Signature: <br />Printed Name: C,CheArvie4S rie-0,P1 <br /> <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 />(Si C10,04:10.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ArTORNEY'S PEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 1708 OF THE LABOR CODE, <br />e14e._ fehessr/20441 (C.57 licensed authorized representative), hereby <br />authorize Get) ae-64 C U CAS e <br />to. sign this Soon Joaquin County Well Permit Application on my behalf. I underatsnd this authorization is valid for <br />one (i) year and 13 limited to the work plan dated on the front page of this application, <br />547-21100 / Mi <br />License e.