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San Joaquin County Environmental Health Department <br /> VVELL & BORING PERMIT APPLICATION SUPPLEME14T^,L <br /> JOB ADDRESS. 11200 ISI Furry Road, Loda,CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing 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#: 7�1t0079 Exp Date: 7-31-2015 <br /> Date: Q:1 � Contractor: Woodward Drilling <br /> r <br /> Signature, � .G_ a, Title: <br /> Print Name:—o r 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 perfori-nance of the work for which this <br /> permit is issued. <br /> X 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 /> Policy BNumber:Carrier: NY Marine&General InsuarncP VVC 201300004258 <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 Signature: dro"Z.0 <br /> U _ � <br /> k�rinL F�lan�Ic: �Vl(':c1nr F' , 1r\��--�,`r�_a <br /> VVARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAU4'r4 AND SHALL SUBJECT fiN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR Ica SEC o`fOW 3700 OF THE LABOR,CODE. <br /> AUT HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of 0-57 licensed authorized representative), <br /> hereby authdoze (print narrre) Frederick A Yukic , to sign This San Joaquin County 1,Vell & Coring Permit <br /> Application on my behailf. I understand this a`rl.honzation is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> I <br /> EH029.01 05!08112 IPEL-?ERS.STAPP <br /> 1' <br />