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07/07/2003 11:46 19166385611 CASCADE DRILLING INC PAGE 02 <br /> ` 71/07%2003 39:03 918BE130 SECOR • FAuZ 02/0« <br /> r San Joaquin County Environmental Health Services, Unit 11 Well Permit Appifcation Supplement <br /> JOB AIDDRESS: de4i�! 4'f1 z PERMIT Bill <br /> I � <br /> LICENSED CONTRACTORS DECLARATION (L D) <br /> hell 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 end my license is in full force and effect. / <br /> License#. L6 -7 -7 �� n Expiration Date: = -_� N <br /> Date 7 - 7 - 0,3 Contractor. In.� <br /> Signature: TI'll Q <br /> Printed nema: <br /> WORKERS' COMPENSATION DECLARATION <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 consent to self-insure for workers'oornoensatlon,as provided for by <br /> 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 Socuon 3700 of the Labor Code, <br /> for the performance of the work terwhich this permit is iesll Myworkers'cOmpensa*,n Insurance <br /> carrier and policy\�numba's are, <br /> A j <br /> Carrier: (N �\�l. Wal POIICy Number: <br /> _ I oemly that in the performance of the war'<for which this permit Is issued, I shall not employ any person In <br /> any manner so as tO become ewil to the wCrKer9'compensatlon laws of California. and agree that if I <br /> should become subject to the workers'99mpenaetion provisions of Section 3700 Of the Leber Code, I shall <br /> forthwith comply with tMeae provisions. <br /> Date:_ Signature; <br /> Printed Name: D _ <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,ANb SHAD,SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADP1l TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DAMAGES AB <br /> PROVIDED FO)MN KCTIO106 OF INC LABOR CODE. <br /> I,—. (slynetun ofC•57 IloenaW autho :ed representative), <br /> hereby aua lxa(print •1 C�/��TD� .SE�dQ <br /> to sign this San Josquln County Wall Permit Application on my Wharf, I undareiand this authorization Is valid for <br /> one III year and Is Itrrlmea to the work plan dated on the front page of this application, <br /> L551 7-20OD/MI <br />