Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADDRESS: /6)-/ ry 3 �� s+ <br /> S�Gc <br /> 4" -, PERMIT SR# <br /> Cion/S2 07 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the <br /> Provisions of Division 3 Of the California Business and Professions Code and Chapter g <br /> (commencing with Section 7000) of <br /> License#. 938110 Y license is in full force and effect. <br /> Date: 10/11/2012 Exp Date: 9/30/2013 <br /> Contractor:Cascade Drilling, L.P. <br /> Signature: ��-� �__ <br /> Title: Sr. Operations Manager <br /> Print Name: Paul Snelgrove <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty Of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> Provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> Permit is issued. <br /> X I have and will maintain workers' compensation insurance, as re <br /> Labor Code, for the Performance of the work for Which this permitdis issued on MyOworkerse <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:Alaska National Insurance Co. <br /> Policy Number: 12JWS30531 <br /> I certify that in the performance of the work for which this permit is issued, <br /> law of California shall not employ any <br /> person in any manner so as to become subject to the workers' compensation , <br /> and agree that if 1 should become subject to workers' compensation provisions of Section ifor of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10/02/2013 <br /> Signature: <br /> Print Name: Paul Snelgrove <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL, FINES UP TO$900,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize(print name) (signature of C-57 licensed authorized representative), <br /> to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for one year and is limited to the work <br /> Plan dated on the front page of this application. <br /> EHD2"I 0$/09/12 <br /> WELL PERMITAPP <br />