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64/28/2600 10:11 7673745677 WOODWARD DRILLING CII PAGE 81 <br /> 04/28/2000 09:50 209468 � FIFTH FLOOR later 02 <br /> „ _$arr:Jisgq _ it} r tom.on AitlrNbn(hm's A, 7i1ea�¢ <br /> 7Efisvl .i�.. •I�ril�;iV: __. _ ' iri��1 �� - • <br /> LICENSED CONTRACTORS DECLARATION (tel � <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sel0on 7000}of Division <br /> 3 of tha Business and Professions Code and my Ilcanse is In full foyer and efle0t <br /> License to 9-7 4? Exp'irvtion rata: 7LOt <br /> Date. - ....,.,_ _Contractor: <br /> manture. Le.� �� Title: <br /> 47 <br /> PrhTW name= W <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under p+enAlty Of perjury one of the following declarations: (CHECK ALL,TINAT APPLY) <br /> I hove aril will maintain a certificate of croaWt to self-insure for workers'campansatlan,as provided for by <br /> Section 3700 of the Lober Code,for the perk frranoe of the work for which this permit is Issued- <br /> AI have and will malrfain workers'compeneation insurance,as required by Secfion 3700 of the Labor Code, <br /> for the performance of the work for which this permit Ie issued. My workem'compensafion insurance <br /> oarrie r and policy numbers aria. <br /> Carrier: Policy Numt*r: 616-jO-0 <br /> I oortify that in the performance of the work for which this permit is Issued, I shall not employ any person In <br /> any manner 0o as to became subject to the workers'compensation laws of Califorrtie,and agree that if I <br /> should became subject to the workers' compensation-provisions of Section 3700 of the tabor Code,l shall <br /> forthwith comply with those vrovisibns, <br /> Date: Atzg dog Signature: <br /> Printed Name: C�o�cf w GJo <br /> WARNING:FAILURE TO SECURE WOWS RS'COMPENSATION COVERAOF IS(JNLAWpUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIAIyINAL PENALTES AND CIVIL FINE$UP TOONE HUNDRED THOUSAND DOLLARS <br /> ($100,000j.IN ADDITM TO THE COST OF COMPENSATION,INTEREST,ATIMRNEY'S FIM.AND DAMAIaES AS <br /> PRCM0915 FOR IN SECTION 3106 OF THE LABOR C150M <br /> 1, (FST lWcerwed autnorla[ed repiosena0wa).hereby <br /> auttiortxe � .- Ch1 � <br /> to stgn this San JN quip County Will Permit Apift tion on my behalf. I Underaeund this aUIhoriMOOR is valid for <br /> one 11 ear and is Ilrrtlted to the walk pMR dMd on the front P&SM of this <br /> APR 2 8 2000�� <br /> ENVIRONMENTAL HEAL <br /> PERMIT/SERVICES <br />