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06/13/2006 17:17 n 7073745677 WOODWARD DRILLING CO PAGE 01/01 <br /> . 002/00; <br /> San JoaquinCounty Environmental Health Department Uni{I......._-._, ,_..,. . <br /> Iv..We Permit Application Supplement <br /> JOS ADDRESS: FI PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> iI hereby affimr that I am licensed andat the provisions of Chapter 9(commencing will+ 9ectlon 7000) of Division <br /> 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License*:-7/0022 Expiration Data: Z/ '7 <br /> -- <br /> G s O <br /> IDote: G �Contractor1: cX000 j��' �L �6 <br /> I, Slgnatur _E, J Title: <br /> Printed name: C Oyc / nJ c� T _ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty Of perjury one of the following declarations: (CHECK ONE) <br /> i <br /> I have and will maintain a certificate Of consent to self-insure for workers'compensation, as provided for <br /> ✓ y Secbon 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 370D 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. F ( -/t D Policy Number O 4e4/ ,00a 6 a38� <br /> I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in <br /> ony manner so as to become subject to the workers'compensation laws Of Callfomia,and agree that it I <br /> should b0cOma subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Oat@: Signature: <br /> Printed Name: C-0l ,3 C/ W i I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT ' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOX.LARS <br /> ($700,000,), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS I <br /> PROVIDRO FOR IN SECTION 3700 OF THE LABOR CODE. <br /> i AUTHORIZATION FOR OTH /IR THAN C-57 SIGNING PERMIT APPLICATION <br /> I' ------- �' �^k''r-�'�(aignature ofC-6711censad authorizod re <br /> � presangtivo), <br /> I hereby authorlm(print <br /> to sign this San Joaquin A q County Woll Permit Application on my behalf. 1 undgra;gnd this authodxgGon is valid for i <br /> one(1)year and Is,limited to the work plan datoa on the from page of this application, <br /> 8.29.03/,MI-, <br /> IAII1,:�a".uql <br />