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Wav/ <br />/s /4 2, 3, <br />in County Environmental Health Department it IV Well Permit Application Supplement <br />JOB ADDRESS: g-147$ Ot Si kTMA PERMIT SR#: 60509Y„2-- <br />0E/11/2O7 11:36 7073745677 <br />05/11/2007 00;10 5300700005 <br />WOODWARD DRILLING CO <br />STRATUS NO CALIF <br />PAGE 03/03 <br />PAGE 3/30 <br />License <br />Date; ig,„-\ \ -CA Contractor: , I/ fte , . 0 1,11A a k,. 0-0 <br />Signature: )1N\ZAJA.,*, T, \;)FILAQUA.,_____ TitleaC li ' <br />% <br />Printe.d name: 0 III 11 a f" <br />1 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the fallowing deolorationa: (CHECK ONE) <br />X, I have and will maintain a,certificete of consent to self-Insure for workers cernpensation, as provided for <br />by Section 3700 of the Labor Code, for the performance or the work for which this permit is issued- <br />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: <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 worl<rars' 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 <br />forthwith comply with those provisions. <br />Signature; tf\r\ c) t.,1 A-) ?9,t9Ct VII <br />Printed Name; II 1 , . <br />WARNING; FAILURE TO SECURE WORKERS' COMPENSATION cOveRAOE IS UNLAWFUL, AND SHALL SUEJE,CT <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 I-AEOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />._I j4.A41. <br /> (signatkire ofC-57 licensed authorized representative), <br />hereby authorix tint name) <br />to sign <br />this $ao ,loaquin County Well Pmt Application on my behalf. I understand this authorization is, valid for <br />one (1) year and i% !trailed to the work plan dated on the front pasts of this application. <br />8-29-02 / MI <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirrn that am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />I of the Business and Professions Code and my license is in full force and effect <br />Expiration Date: <br />Policy Number:0 Li LI -00 ao az,) <br />Date:10 -\\„