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03/30/2006 13: 24 2098458 HOLDREGE&KULL PAGE 02/02 <br /> bJ/:i0/2fl@R 17:95 707677 •WOODWARD DRILL CO PAGE 61/01 <br /> ttlaff 7' <br /> San Joaquin County Environment earth Department U-nit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2, 530V <br /> 330 9(o5 5 . Eat c, PERMIT SRN: 00`{(01'1 <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 <br /> iProfessions Code and my license is in full force and effect. <br /> License#: I 1 y tI ( Expiration Date: 7 <br /> r <br /> Date: ��.�Contractor' <br /> Signature: 141 tkI O <br /> Printed name: <br /> WORKI=RS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br /> I have and will maintain s Certificate or consent to self-Insure for workers'compensation, as provided for <br /> by Sectlon 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> Ur 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%morkers'COmpensatfon insurance <br /> carrier and policy numb �_p re; <br /> Carrier: 1-t» .��Policy Number:-Q �9 <br /> I Certify that in the performance of the work for rmhich 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 td the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with tho:aeprovivons, <br /> Expiration Date:.. 14V/W Signature: °y '^(X�/ ({ /( I <br /> Printed Name:�' "1 h�- �,/ CJU�( L&- <br /> WARNING: FAIIJJRE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT,SUBJECT <br /> Al 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 /> PROvIDEO FOR IN SECTION 3700 OF THE LABOR COPE, <br /> AUTHORIZATION FOR OTHER pTHAN C.57 SIGNING PERMIT APPLICATION <br /> 1, f5r ,�(IAJ't7r'�_ , <br /> _(sigma o'Cd7llcensed atrthodzedaval� <br /> hereby authorize(print name ( <br /> to sign this San Joaquin County Well Permit Application c n my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front,page of this application, <br /> i IMl <br /> UID 2M2401 <br /> 5/28/04 <br />