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Sara:Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 11200 N Furry Road,Loda,CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licenced under the provisions of Chanter 9 (cornmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License##: 710079 Exp Date: 7-31-2015 <br /> Date: Contractor: Woodward Drilling <br /> Signature) Title: \ <br /> Print Name: ( o o <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> )r I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> NY Marine&General Insuarnca WC 201300004258 <br /> Carrie: Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10-1-2014 SlgllaftBrO: l Vpz.d a/M Z <br /> r v <br /> Prant <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLf:WF ,AMD SHALL SUBJECT AN EMPLOYER TO <br /> 'Cl',Mlr]AL`MNIAL-nES AND'°CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATT ORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE L, BOP.CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby auth raze (print nanrse) FradericK A Yukic , to siren Fhit� San Joaquin County Well & Coring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is Ilnnited to th;;� work <br /> pian dated on the front pace of this application. <br /> i <br /> -CHD 29.01 05=11*2 1PELJ_PER..':T APP <br />