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07/30/2001 09:37 707374 -7 WOODWARD DRILL'- ' CO PAGE 02 <br /> San Joaquin County Environme ,tal�ea th S erv/ ices nit(V Well Permit ApplicationSupplement <br /> JOB ADDRESS: <br /> / C.C%C. 0PERMIT SR#: <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#: U O 17 41 Expiration Date: <br /> ri d �-- <br /> Date: '30 of Contractor: W coo.V w A4 Q-D <br /> . Signature:ze-"'^� Title- f Ef'/a t 20 7 <br /> Printed name: dN G <br /> WORKERS' COMPENSATION DECLARATION <br /> ) 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 /> 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: '157� <br /> Policy Number: 4.2 o a <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 LaboCode• l shall <br /> forthwith comply with those provisions. <br /> a 0/ Signature: <br /> Date: 7 -� <br /> Printed Name: o .-✓ /•-�' ��+�D ole L��h�-��_ � <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 /> ($I OF <br /> IN FORINSECTION 3706 OF THE LA OR CODE�ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> P <br /> � ,• , r �,�Q,�,�_ (signature ofC-57 licensed authorized representative), <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 /> 5-17-20001 Ml <br />