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-'01/24/2006 10:47 7073745 WOODWARD DRILLIhkPAGE 02/02O - <br /> . � I <br /> 6JI21 V 3 i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> i <br /> .JOB ADDRESS. Z©D lU � PERMIT SR#: <br /> i <br /> i <br /> i <br /> LICENSED CONTRACTORS DECLARATION (_ CD,� <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* I DO7 al_ _ --Expiration Date: -7 17) 2a D <br /> Date: -2-4 -a t/ Contractor. W o OJ W Av� D V l 1 h �I �h e__ <br /> SigrtStllre_ Title: T SCI pG0,U l <br /> Printed name: em C f lU[�_. . G d D-D 4 - r) <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-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 /> far the performance of the work for which this permit is issued- My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: �;� __- LL..IV?� _ Policy Number, <br /> I certify that in the performance of the worts 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 l <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, Is <br /> had <br /> forthwith complythose provisions. <br /> Y <br /> Expiration Date: D Signature:2 <br /> 4 ,„..•. <br /> Printed Dame; COXC/ 1 , . <br /> WARNING:FAILURE TO SECURE WORKERS'COMPLWSATIQIH COVERAGE IS UNLAWFUL,AND SHALL SUBJECT � <br /> AN EMPLOYER TO r-RININAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($900,000.),IN ADDITION TO THE COST OF COMPENSATION INTEREST <br /> ATTQRruErs FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR 0T'H AN C-57 SIGNING PERMIT APPLICATION <br /> I, Crc-J slgnatore oIC-67 Ilconsed authorized representative), <br /> p ), <br /> horeby authorlae(print name) pe en <br /> to sign this San Joaquin County Well Permit Application on my behalf. t understand this authorization Is valid for <br /> one(1)year and Is lirnibed to the work plan dated on the front page of thts application. <br /> 8-2802 f MI . <br /> F.HD 2". 2-001 <br /> b12t/oa .. <br /> fr <br />