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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 #: C -6 7 14 7 ot:)1cf Expiration Date: 7- 3 eø0.2, <br />Date: 1— It—Ci Contractor: CA.) 00 akih <br />Signature: OfrigA77ciou P7A1,04disaft. <br />6,e/X- er0e5Sneo irs'N <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following 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 />/c- 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 />Carriar 7ATh _pout), Policy Number: _00 ZO 0 3 e <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 taws 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: lq.01 Signature: <br />Printed Name: Cerot ce/E.S. 7Rinfrv1 <br />WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AM EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, A TTO RN EY S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br />1, eieh4 rIlessneaol (C-57 licensed authorized representative), hereby <br /> <br />authorize a .c..0i266 Co /Q 06/2-SE <br />to In 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 />5-17.21300 / MI <br />Printed name: <br />09/19/2001 09: 48 7073745677 WOODWARD DRILLING cn PAGE 13 <br />00/15/2001 11:48 20e -579-2225 MODESTO ATC PAGE 03 <br />JOE ADDRESS: ..3)(7 WV ;444 -e PERNOT SR#: ,0275iv <br />San Joaquin County Environm ent,\: Health Services, Unit IV Well Permit Application Supplement <br />LICENSED CONTRACTOR'S DECLARATION (LCD)