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02/14/2005 16: 34 9166385 CASCADEDRILLING PAGE 02/02 <br /> • <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADORES: Icy Fest- }}p rs{I n W It <br /> SR#• V1 )Ifo <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(Commenting with Section 7000)of Divislon <br /> 3 of the BU91ness and Professions Code and my license Is In full farce and effect. <br /> License#:�`7 ( 7 c ( Q Expiration Date: <br /> Date: ! OS tote" <br /> Signature: Co Title:lt^ t <br /> 1 <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of oonsent to setRinsuro 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 /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: Y1� policy Number:Wit• 7 Q$3 <br /> I certify that In 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 it I <br /> should become with✓the, <br /> to the workers'compensation p wsions oi5 ctlon 37 0 of ih gbcr Code,I shall <br /> forthwith comply wiC !hose provisions. <br /> Expiration Dato:!S—I' C7 Jr Signature: <br /> Printed Name: Si -&r-, K t a t��),�__ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT.SUaJEC7 <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ISt00,000.), IN ADDITION T6 THE COST OF COMPENSATION,INTEREST,ATTORNErS FEES,AND DAMAGES As <br /> PPROVIDED POR IN SECTION 3706 OF THE LABOR CODE, <br /> AVIORIZATI N F OT(ER THAN 0.57 SIQNING PERMIT APPLICATION <br /> 6 (signature ofC-57 licensed authorised representative), <br /> hereby authorize(print name) <br /> to alga this San Joaquin County Well Permit Application an my behalf. I understand this authorization Is valid for <br /> ane(t)year and 14 limited to the work plan dated an the fronta o of this e <br /> P 9 PWiaatlon. <br /> 6-29-021 MI <br /> XO W29-obOD1 <br /> 6!x7/04 <br /> �9/z9 �nba aooas <br /> 9£b0L969L6 90:9L 5992/bL/Gr0 <br />