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07/30/2001 09:37 7073745E-" WOODWARD DRILLIf`-00 PAGE 02 <br /> �✓ v' <br /> Pto - IR - cc <br /> San Joaquin County Environmental Health Se ces, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: zq-00 <br /> Ag <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#: `7 t U 0 r? Expiration pate: I <br /> Date: 3 d e ( Contractor: W co D w A,A. <br /> Signature: Title' f e Ere a�T -- <br /> Printed name: d e)NC- ' ori n�A <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> 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 /> Carrier. 15 7 Fel Al E) Policy Number: 4-Z e) -;L 3 <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 <br /> forthwith comply with those provisions. } <br /> Date: rJ o G/ Signature: <br /> Printed Name: .�✓ ��' L✓D o2 ea r_J <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CREMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGESAS <br /> PROVIDED FOR IN SECTION 370$OF THE LABOR CODE. <br /> sl nature ofC-57 licensed authorized representative), <br /> L ." <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 /> 5-17-2000 t Mi <br />