Laserfiche WebLink
08115!2@61 12:42 7073745677 WOODWARD DRILLING CO PAGE 02 <br /> ' + 1PAGE 03 <br /> fit311S12001 11:48 _439-5',�2 5 MOUE97Q ATG ti..� <br /> San Joaquin County rEnvironMental Health Services, Unit IV Well Permit Application Supplement <br /> JOB AE}DRF-SS:�.� E f Q w�IaNT T PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions-of Chapter 9{commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#; C'S? ! t- --- .----Expiration Date: <br /> Date, gwr�'Q i Contractor. W ?Q0 W►49:A A91- _ <br /> jG <br /> Signature' ""- - ^ <br /> Title: J� rS 17►3Nr �,6 <br /> Printed name: <br /> WORKERS' coMPENSATION DECLARATION <br /> I hereby affirm under penalty of per)ury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have and vAit ma},ntairn a certificate of consent to se&nsire for workers'Compensation,as 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 maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' carnpensatian insurance <br /> carrier and policy numbers are: <br /> Garrtttr: `JTTE ti ti Policy Number: 02.4�3 � - <br /> 1 certify that in the performance of the work for which this permit is issued, l shall not employ any person in <br /> any manner so as to becorne subject to the workers'compensatior: laws of Califomia, and agree that if I <br /> sF.culd become sut�ect to the workers'cornpensatlon provisions of Section 3700 of the tabor Code, I shell <br /> forthwith comply sMth those provisions. <br /> Date: �K-Oi Signature: ,�r .- <br /> _ Printed Name: 92L*4 <br /> I WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C0Vtk-*kGE IS UNLAWFUL,AND SHALL SUBJECT <br /> f AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IS100,000.),IN ADDITION TO TETE COST OF COMPENSATION,1NTERFST,ATTORNEY'S FEES,AND CAMAGES AS <br /> PROVIDES} FOR IN SECTION 3708 OF THE LABOR C01315. <br /> t ,C/IC LSSTI (C-57 licensed authorized representative),hereby <br /> authorize +aN W <br /> to sign this San Joaquin County WOII Permit APO'Catton on my behalf. I understand this authurization 15 V21id for <br /> one(9)year and is limlted to the work plan daled on the front page of this apPllcatiori. + , <br /> 5,17.2000 1 MI `, <br />