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07/30/2001 09:37 707374E -7 WOODWARD DRILL? CO PAGE 02 <br /> Sari Joaquin County Environm <br /> ental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:/pgqPERMIT SR#: jQ02LtO3 <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 /> Date:iration O — <br /> .. License#: � � � � Expiration <br /> Date: `� 3 4 t Contractor:,_ W Qo n w ,e.T? fl�-` <br /> Signature: ( Title: / <br /> Printed name: do—A-)G <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> T Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> �C l 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 /> Carder. ,45 �U JU Policy Number. <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 a ree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the LaboCode. I shall <br /> forthwith comply with those provisions. <br /> Date: <br /> Signature: <br /> Printed Name: �' a .✓C i.� E �� w 17--- <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 /> PISECTION 3T 6 OF THE <br /> DDITION To THE COST N F COMPENSATION,OR INTEREST,ATT'ORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> , a,..�_ (ssgnature ofC-67 licensed authorized representative), <br /> 1, 1 <br /> L <br /> AJ <br /> hereby authorize(print name) <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 /> SA 7-2000 1 MI <br />