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01/10/2004 16:23 FAX 707374430 Woodward Drilling , Z002 <br /> 1,0/11/2004 16:08 20946BJtowd FIFTH FLOOR PAGE 02 <br /> y <br /> San Joaquin County Erivironmental HealthDepartment Unit IV Well Permit Application Supplement' <br /> JOB ADDRESS: �7 s; � ' I� �C PERMIT SR#: <br /> y <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(commencing with Section 7000)of Division <br /> 3 of the BUSM986 and Professions Code and my license is in full force and effect. <br /> License 0: 7Z 0029 Expiration Date: ZJ 1 �-r /�•y/l f r <br /> Date: � Controctor: / <br /> Signaturo• S �.-4 Title• <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I hs�e and will Section 3700 o thetain a Labor Code,ffoeof consent to self4naure for r the performance of the work for wh ch this permit is Issuedvided for by <br /> have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Co 'e, <br /> for the performance of the work for which this permit Is issued. My workers'compeneation Insurance <br /> carrier and policy numbers are: <br /> Carrier:_ ST&2L ;=tee A.1 17 Policy Number:�Q A: � ���U—y— <br /> I certify that In the performance of the work for which this permit is issued, 1 shell not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of.California,and ogres that I 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith comply with those provisions. <br /> Date. OAw Signature- <br /> printed Name: G!/� k 1A )�i� �l tA2i4 2 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> ($I00. R N I CnON 37E COST OFT tOFCOMp NSA'rION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOLABORCODE <br /> I' r (signature atc-ST licensed authorised reprwwntettvs), <br /> hereby authorlxe forin name} <br /> to sign this San Joaquin County wall Permit Application on my behalt 1 understand this authorization is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this appRoation. <br /> 1.25-021 MI <br />