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'01/24/2006 10:47 7073745677 <br />42' 2, <br />/taxi/ <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 7(0260 A/6-W-C.e., <br /> <br />PERMIT SR#: <br /> <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />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 # C5 -7 .'--/ !Oa? CI Expiration Date: 1 i )—(-) 0 --/ <br />Date: I - ----''''4 -° I, Contractor: WO 0cittV,117-.=1 -1) V i 1 <br />Signature: (4->ffl-f,- ' ....-- 6363-?-z(2.......,-0-J2-, Title: <br />Printed name: name: OC / A.." <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br />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 />Carrier: SMI-E 1-7 A) 7) Policy Number: 00 b 313 <br />E <br />Printed Name: COAJC-//06g. r2 <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 />($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 />AUTHORIZATION FOR OTHkRTHAN C-57 SIGNING PERMIT APPLICATION <br />C <br />ofC-57 licensed authorized representative), <br />' <br />hereby authorize (print nm ae) 1.°e. P'\ <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 />8-29-02/M1 <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 3700 of the Labor Code, I shall forthwith comply wit 'those provisions, <br />Expiration Date: j /2 00 14%1 Signature: <br />WOODWARD DRILLING CO PAGE 02/02 <br />END 29-02-001 <br />6/22/04