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IU 6/22'92 13:58 19166385611 CASCADE DRILLING INC PAGE 02 <br /> _. L/A/g2 WED 12:53 FAX 1 911 -1 0400 5Ecolt-SAOCKINWIV --� <br /> JOTSSan Joaquin Ceuf y ErrvironmenUl Health Services, Unit IV Well Permit Applicatioo'nn Supplement <br /> JOS ADDRESS IZD p PERMIT SRS: DL/ ✓ �o <br /> CU�eI a a4 fl,1, W1 W-i31 hiuY1L) <br /> LICENSED CONTRACTORS DECLARATIONL( Cpl <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 1000)of Dlvislon <br /> 3 of the Business and Professions Code and my license is in full torte and effect. �f <br /> License#: G S ` 2/ 7-S-10 Expiration Date: / 0 / <br /> Dill/0 - 6 - o Contractor //i- --- <br /> Signature: 0,07 F <br /> Title:Q e r�Q 7T d <br /> Printed name: <br /> WORKENS' COMPENSATION DECLARAT16N <br /> I hereby affirm under eanaky 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'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the porformanoe 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 ponormares of the work for which this pormit is issued- Aly workers'compensation Insurance <br /> "rifler anno polity numbers are: <br /> /7 � <br /> Carrier_ fi /a S/'/�Ce /s d 14 Z Policy Number: 0 �� S �OS 3 <br /> i <br /> I certify that in the performance of the work for which this permit is issuod, I shall not employ any person to <br /> any manner so as to become aubjoct 10 the workers'componsation laws of California.and agree that 01 <br /> should b000me subject to the workers'Compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: � a- Signature: ' -- <br /> Primed Name: L 4O� <br /> WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PCNALTIEB AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,/IpEO FOR ADDITION <br /> SECTo ON 9106 OF THC LA <br /> BOR NS TION.INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVi y ��rQ -/1 G{ IYl 0./L _ ,(algnstJurel(ortt{c-577 licensed authorized representative), <br /> herebyeuthortze(pdfd name) <br /> to sign this San Joaquin County Well Permit Appllwflon an my bohaf- I understood this autholintion Is valid for <br /> one(1)year end is fleshed to the stork plan datad on the front Page of 111116 aPPlicil len. <br /> 5.17-20001111111 - <br /> I <br />