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11/22/2005 08:52 91663PF511 CASCADEDRILLIt" PAGE UL 02/ee2 <br /> 11/21/2995 lu:Jb `!1�04JU stt;utr <br /> >- <br /> X <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplamettt <br /> JOB ADDRESS: �(D y Z� CAtt /'r' jqE, PERMIT SR#: 151 ( 2— <br /> LICENSED <br /> I ( 2-LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby 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 and my license is in full force and effect. <br /> License ft:C- ' Zl 3-1 Z) Expiration Date: /- 31 - Cr. <br /> Date; //^ o,Z� ^C/oa, (CJonmmctor,_ 111 <br /> Signature: / Tltic:-C Aikaw#C <br /> '�e <br /> Printed name; —2 "`� <br /> WORKERS COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followirg declarations! (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is Issued_ My workers'compensatlon insurance <br /> carrier and policy numbers are: <br /> Carrier: r Policy Number:-9-2f O S 3 J <br /> I certify that in the performance of the work for which thls permit is Issued, I shelf not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Callibmia, and agree that if I <br /> ahWld become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shay <br /> forthwM comply with those provisions <br /> Expiration Date:5-�L� 01-Signature,• , // <br /> Printed Name:_ i1st` - , `}tip• u� � <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COYGRAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPI,QYER TO CRIMINAL PENALTIES AND CML FINES Lip TD ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, <br /> /+ / r� (x141`10 arre OFC47)icensed authorized mpf"entauve), <br /> hereby authorize(print name) iT 2 Lr ,- /e efy4, <br /> to 91gn this San Joaquin County Well PermitAppooation an my behalf. I understand this authorization is valid for <br /> one(1)year and is limitnd to the work pinn dated on the front pag0 of this 3PPlmcarion. <br /> 8-29-02/MI _ <br /> Tar@ 2q-02-091 <br /> 622104 <br />