Laserfiche WebLink
03/26/2007 15:16 7073745677 WOODWARD DRILLING CO PAGE 02/02 <br /> FSan Joaquin County Environmental Health Department Unit IV Well Persalt Application Supplement <br /> OB ADDRESS: �� /�el� PERMIT SR#: At 35) <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 0: y1 i! 04 9Expiration Date: `7 <br /> Date; Q3-"::0 Contractor; 1*AA,c,0 <br /> Signature: <br /> Title:_29-fm ID cal-C <br /> Printed name:—dali,c9er—E. WMW80 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under ponalty of perjury one of the following declarations; (CHECK ONE) <br /> I have and will maintain a certificate of consent to solf-Insure for workers' compensation, as provided for <br /> by 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'compensation Insurance <br /> carrier and policy numbers are; <br /> Carrier:_ 5 r�"C- I"L4MD `Policy Number: 0 t) ao Q:: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration pate: Signature: <br /> Printed Name: C100Ci o W <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT,SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I' sl9nature ofC-87 licensed authorized representative), <br /> hereby authorize(prl ema) ' 't.w ,D6 <br /> to sign this Sen Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for , <br /> one(1)year and Is Ilmited to the work plan dated on the front page of this application. <br /> 8.29.02/MI <br /> }r,h(C)29-02-001 <br /> 6/22/04 <br />