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01/10/2004 16:23 FAX 7073744` Woodward Drilling Q002 <br /> 1�.,�.� FIFTH FLOOR PAGE 02 <br /> • 2.0/11/2004 16:08 2094683433 <br /> y <br /> San Joaquin County Emrironmentat Health D..evartment Unit N WeH Permit App <br /> 11 lication Supplement' <br /> 074,1 -7,57 ' S� PERMIT S►R#: �° 39936 <br /> JOB ADDRESS. 7--4'<14�y <br /> LICENSED CONTRACTORS DECLARATION COW) <br /> I hereby affirm that i am licensed unclthe e and my license nsef is in pier 9full acne and etfecg with Section 7000)of Division <br /> 3 of the Business and Professions 'Z <br /> Q Q `� Expiration Date: <br /> License#: � �`�• <br /> Date: , D U Contractor. . <br /> Title:Slgnalure: <br /> Primed name: • <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> as <br /> t have and will maintain a certificate of consent orf an�of the woorrkfor'whihich this perrmmitt Is issued. for by <br /> Section 3700 of the Labor Cade,for the p Sect 3700 of the Labof Co e. <br /> have and will maintain workers'compensation Insurance,as required by eh$ation insurance <br /> for the performance of the work for which this permit is Issued. My workers'comp <br /> carrier and policy numbers are: Dt 61 3� <br /> policy Number: <br /> Carrier. Permitis an erson in <br /> 1 certify that in the performance of the work for which this 8aws o!08sued,I ' the <br /> andaOgres that If I <br /> any manner so as to become subject to the workers compensation <br /> should become subject to the workers•compensation provisions of Seotlon 3700 of the Labor Code,1 she <br /> ll <br /> forthwith comply with those provisions. <br /> Date'. Signature: <br /> � <br /> Alprinted Namo: G <br /> INC:FAILURE 70 SECURE WORKE".D CML FINES UP?�b Np THOUSAND DOLLARS RAGE is UNLAWFUL,ANv SHALL SECT <br /> WARN ETH FEES.M AND DAMAGES AS <br /> AN EMPLOYER TOO CRIMINAL PENN.t1E8 AN <br /> (S1 oo.0oo.),IN ADDITION 5 CTlON 37Q6 OF T1iEFLA80R C4DEION.INTEREST ATfORN . <br /> PROVIDED FOR i <br /> (signature 0fC-5T Ilcansed authorised reprasontstive), <br /> 1, <br /> hereby authorize(pdn name) ron 1s valid for <br /> to a19n this San Joaquin County Well permit Appg�on on my behalf. t understand this authorized <br /> one(1)year and b limited to tha work plan dated on tho front pays of this appil�lon. <br /> 1.25-021 MI <br /> r <br />