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10/16/200. 13:50 19166365671 CASCADE DRILLING INC PAGE 03 <br /> Uai 02_ MED 12'93 FAX 1 9.' 41 0030 %ErOR'-ShORANEWO lib 002 <br /> I <br /> San Joaquin County Envlrennlental Health Servl0e9,Unit IV Well ParrhN Appllooattlort Supp9Mmsnt <br /> JOB ADDRESS p PERMIT SR#: w <br /> (VMVM 21 t � w - M1W"r�) <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 naraby attlrm that i am liansad under the provisions of Chapter 9 (commencing with Section TODD)of Division <br /> 3 of the Business and Prolassiona Code and my license Is In full force and offset. <br /> License M" �/ <br /> G S 2 7/7SL( Expiration Date: / —J/—° <br /> Date: ��' b LI <br /> —0 Contractor: C Q SC t:tok Dr-( l/'/ 11 <br /> cf <br /> Signature: Title: VlleC � , o+�S M9� <br /> Printer!name: V e/'o- <br /> CA <br /> C( o M G ✓� i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations' (CHECK ALL THAT APPLY) <br /> _I have end will maintain a cerilticata o1 consant to sell-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Cede,for the parfonnance of the work for which ihis permit is laeusd. <br /> 1 naw and will maintain workers'oompensation nsvranoe,as required by SIction 3700 Of rhe Labor Code, <br /> forth*performance of the work for which this permit Is Issued. My workers'oompensatinn Insurance <br /> carder annS Ka d policy numbers am: <br /> carrier 14/a r " � l�i d�a Policy Number: O S� I <br /> _I certify trial in the performance of the work for which this permit IS UsuaQ I$hail not employ any parson in <br /> any manner ae as to baoome eubjeot to the workers"compensation laws of California, and agree that A I <br /> Should b$COma SubjeCI to the workers'compansatlrn prnvistons of Section 3700 of the Labor Code, I shell <br /> letthwith comply with those provisions. <br /> Date: Q /� ' a'�Piynature: <br /> Printed Name; Ar" ✓I�I a -- <br /> WARNING:FAIWRE TO SECURE WORKERS'COMPENSATION COVCRAOE IS UN4r►WFUL.AND$HALL SUBJECT <br /> AN EMPLOYER TO CItIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ADDITION <br /> TN THE 40OnF 1'o LABOR COOEiON,INTEREST,ATTORNEY'S AmS,AND DAMAGES AS <br /> PROVIDED FOR1 <br /> I, V e. rGt. C/L Ca r r l �i / `� —tderu,ur.CfG87,iownwd.athcriuA rapraaaafataraJ. <br /> herebysumorw(printnama)_ L�tr%tJ fiPxt , SECOa✓iY1�U'I�6119�10�7A1 Ihu <br /> to sign this San Joaquin Cwrrty Well PermR Appllostion on my behalf. I undetsWnd thle authorkeaon Is valid ter <br /> Ora(1)year and Is amned to the work plan dated on the grant papa of this SP011 stion. <br /> 6-17-2000/W _ -- <br />