Laserfiche WebLink
08/15/2001 12:42 7073745677 WOODWARD DRILLING CO PAGE 02 <br /> .08/15/2001. 11.:48 209-5?° '125 MODES'V0 ATC PAGE 03 <br /> San Joaquin County tEnvironrnental Health ServlC09,Unit IV Well Petmlt Appiieation Supplement <br /> JOB AQDRESS: w fE�'^oNT r PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 12m licensed under the provisions-of Chapter (commencing with Section 7000)of Division <br /> 3 of the Business and Profession9 Code and my l'Icen9e is in full force and effect. <br /> License#: : w 7100 7!1 _ Expiration Date', 7- <br /> Date: Si'rw-w Contractor: W N <br /> Signature; "�' Tit10: ?�t7iS 17ax1N14�6�G <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATiOiN <br /> I hereby affirm under penalty of pedury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-•insure for workers'compensation,85 provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will rraintain workers'compensation insurance,as required by Section 3700 of the Lsbor Code, <br /> for the performance of the work for whiG1 this permit is issued, My workers'cornpensaWn inaurancc <br /> carrier and policy numbers are: <br /> Carder: TA-rc >IV4 M_____Policy Number: 0�?0 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 /> .iny manner so as to become subject to the workers'compensation laws of California, and agree that if f <br /> shauid became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date. 5-144-0% Signature: ., <br /> Printed Name: j2L#44 rp <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CavER,kCE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPi.OYIER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNaREC THOUSAND OOLLARS <br /> IS10o,000,),IN ADDITION TO THE CAST OF COMPEN3ATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED Foil IN SECTION 3706 OF THE LAaCR COPE. ' <br /> a�L11!Ss roinw "l (G-57 licensed authoWxed representative),hereby <br /> autharixa f w <br /> to sign this San Joaquin County Well Parma Application on my behalf I understand this authori28006 is valid for <br /> one(i)year and is limited to the work plan dater/on the front page of tilts apPllcatian. <br /> 5.17-2000 11141 <br />