Laserfiche WebLink
f. <br /> 08,,1612000 09: 58 19166385611 CASCADE DRILLING INC P-GE r12, <br /> San Joaquin COUnty 8rivitaromentat Health"Selvices,Untt IV Weil Permit Application Supplement <br /> JOB AUDf2E53' 6��4 Soy 1"f, /}r~s;i�- AOL5t,, . A- PERMIT SR#-. <br /> I <br /> LICENSED CONTRACTORS DECLARATION MM <br /> I hereby affirm that 1 sr'n licensed under the provtsione of Chapter 9(corr,rn®ncinp with 5ec!lon 7000)of pmelon <br /> 3,51111* Ildline"s arn�d PraftlEaions Crile and my Iic enra is in full force find e/ffeCt. r <br /> ILicence#: / _ :71 Expiratlan bate: / — 3 ` ` 0 -- <br /> G <br /> Date: '- � Contractor: S C <br /> Signature: fr � - Title' <br /> IPrinted n2met _ �7 r e .S i^�• 2'� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aMrm under penalty of perjury ant of the following deClarat+.ons-, (CHECK ALL THAT APPLY) <br /> i <br /> _I have and will maintain a certificate of concent to self-insure for workars'compensation, as providiad for by i <br /> section 3700 of the Labor Code, for the performance of the work for Which tris permit is ssu.d <br /> I have and , compenfiaicm insurance, as <br /> red by <br /> ction 3700 of <br /> he t-AbOf <br /> for he perto will <br /> =2 of the work forwhich this permit iS issued, Myrworkerss''ecrrpensetiont oOe <br /> nsu ar)ce <br /> camer and policy numbers are. <br /> ? <br /> Carrier:,� Gt. 0 n a Policy Number: � `�.� <br /> i oerpty chat ire tMe performance of the work for which this permit i9 WUed; I shall net employ any person in <br /> any manner av as to Deooma subject to the workers'compensation ISWs of California. and agree that it i <br /> should beoorne subject to the worKers'compensation previsions of Seaton 3700 of the Labor Cod(,-, I <br /> torthwith Comply with those Provisions. _ <br /> i Date_ Signature. <br /> Printed Name' <br /> WARNING.lAtl.Wtt TO sLaUftll WORKIRS'coMPENSATION GOVER+4GE 19 UNLAWFUL,AND SHALL BUS tQCT <br /> AN EMPLOYeR TO CROANAL PFNALTIE8 AND CIVIL FINER UP TO ON$NUNDRrD THQUSANo DOLLARS <br /> N IN ADDITION TO Oil THE <br /> E cQ -OF CCIIMPIMN ATION,INTIREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED f <br /> (CS7 ticere"d authoitiud r+tyr+eeentstive),Hereby <br /> autharize„,„ ~@�t f C"/ S G fir <br /> to sign this San Joaquin CoLtnty Well Permit Application on nay behalf. t understand this authorization is vatld for <br /> one (1)year and is limlftd to the work Plan dated on the front page of this application, <br /> ?0/72,d 8820 889 S`6 9-)Wl';DS030 N011y DtAl S'T :T T 00017-9T-9n ! <br />