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07/30/2001 09:37 707374'- '7 WOODWARD DRILL7' CO PAGE 02 <br /> "..00l, <br /> San Joaquin Coun Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: � �� e4 PERMIT SR#: 1� <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#: r7 t _0 Q -2 —Expiration Date: r7 O <br /> Date: "il ( Contractor. <br /> Signature: _ �'re-t-ti .� Title- T <br /> Printed name: <br /> WORKSRS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY} <br /> 1 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 /> [ 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: 37 � <br /> Policy Number: en.20 �` 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 Labo�Code, I shall <br /> forthwith comply with those provisions. <br /> ate• � gna <br /> o 0/ Signature: <br /> p <br /> Printed Name: l' o �✓ i•�•' C% ''�D - <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 /> ($10o,o0o.),INIADDITION <br /> N SECTION 37 6 OF COST <br /> OFLABOR NSATCODEION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> �.4 _ (signature ofC-57 licensed authorized representative), <br /> i, <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 f MI <br />