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10/02/2007 10:38 7073745677 WOODWARD DRILLING CO PAGE 02/02 <br /> 10/02/2007 16:24 20945834 EHD • PAGE 02 <br /> San J084uln County Environmental Health Dc I kartment Unit Iv Well Permit Application Supplement <br /> JOB ADDRESS: a PERMIT SR#; <br /> �64Dr-k+z>w,- <br /> LICENSED CONTRAG S DECLARATION (LCD <br /> 1 hereby affirm thaLl am licensed under the provision of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my lie a Is in full force and effect. <br /> License#: 1 O(�� iration Dare: � -!A- ( )G <br /> Date: -\1 b`t Contractor,+ t iT <br /> signature: .I Tttle-�\ <br /> Printed name <br /> (-CA- <br /> WORKERS'OOMPE111SATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fall wing declarations: (CHECK ONE), <br /> —I have and will maintain a certificate of consent tkc el&insurefor workers'compensation,as provided Tor <br /> by Section 3700 of the Labor Code,for the pert racr'ofth'e Work for which this permit is issued. <br /> / I have and wi0 maintain workers'compensation ir uianee,as required by Section 3700 of the Labor Code, <br /> l fop the performance of the work for which this per {t is issued. My wokers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier. Policy Numb": 1 t�' -Vqa IC <br /> I certify that in the performance of the work for this permit Is issued,I shall not employ any person in <br /> any manner so as to become subject to the WoM VcompnnsatiOn laws of Califomia,and agree that if I <br /> should become subject to the workers'compensa on provisions of Section 3700 of the Labor Coda,I shall <br /> forthwith comply with those provisions. <br /> Expiration DaW: 1b -07 Signature: <br /> Printed Name <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN TION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL Fil ES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION-1VTHE COSTOF COMPENSA 1OK iNITEPEST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDPO FOR IN SECTION 3706 OF THE,LASOR CO <br /> �A.UTHORIZCW <br /> AUTHORIZATION FOR OTHERTHA G57 SIGNING PERMIT APPLICATION <br /> (7ltui <br /> I, I�` wr G I (sigoatert ofC•,7 licensed authorized repmaerdative), <br /> Memlty authorize(print nam-)^Q NS oa ATE5 <br /> to sign this San Joadum county Well Permit Application III mmy behalL I undazRgnd this authorization it valid for <br /> one(1)year and is limited to the work plan dated on the#oat page of this application <br /> &29-021 MI <br /> rM saozoon <br /> �zvpa <br />