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11/28/2e@l 11:20 7673745677 IAOODIAIARD DRILLING CO PAGE 02 <br /> ;Art r '')R EN TFLr1Pi016l?GI E5 <br /> `w./ <br /> San Joaquin County EMvirontrtOntal Health Services, Unit IY Woil Permit Application SupptnMenT__1 <br /> { JOB ADDRESS. _�rf�var�5�`3d �G Flat:,& FAr4rr_PERMIT SR#: <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that i am licansed 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 affect. <br /> Licsnse 71 L� _ Expiration Dete: -7 $1 <br /> -- - <br /> Date: Contractor;. _��G2W x+►iz n SIL-L,1'V Cv <br /> SiDnaturo: Title: 0P6P_AYs01,Js jnA0A1rR.�_ <br /> I Printed name: <br /> WORKERS'COMPENSATION DeCL.ARA`tION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of a¢nsent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Cotte,for they performance of the work for which this permit is issued. <br /> I have and will maintain wori,ers'compensation insurance, as required by Section 3700 of the LaWr Code, <br /> for the performance of"work for which,this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrierpolicy Number: C?0:Z02 3f3 <br /> I certify that;n 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 tri the workers'compensation pr vis' ns of Section 3700 of the tabor Code. I shed <br /> forthwith comply with those provisions. <br /> Date: /—2 g�,C31 signature: /4/4 - <br /> Printed Name: „461e14 J';0 557/02 . <br /> t <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSA'nON COVERAGE IS UNLAWFUL,A14D SHALL SUBJECT <br /> { AN EMPLOYER TO CRIMINAL.PENALTIES AND CMI.FINES UP To ONE HUNDRED'THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENIIATI0N,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PftOVIDED FOR IN SECrON 3706 OF'ENE LABOR CODE. <br /> (C•S7 licensed authorized representative),hereby <br /> authorize� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> rine(1)yeAr and is limited to the work plan dated on tha front page of this application. <br /> 5-17-2000/MI <br />