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09/12/2002 13:07 1916631 CASCADE DRILLI6INC ' '.-PAGE- 02 <br /> (a.* SI Lk-K I Uri <br /> o9ii212@02 13:04 '2,094 Z? <br /> San Joaquin County Environmental Health COP atitnent Unit tV Wo� It P �APP©D 25�I�Qt <br /> JOB ADDRESS:;4( 59 IL I AeRa/To.J RM6 PERMIT 3R0: —b <br /> y pD i f cq 95a4 S <br /> LICENSED CONTRACTORS DECLARATION LC <br /> I hereby affirm that i am licensed under the provisions of Chapter g(commancnng with Section 7000)of Dlvlslon <br /> 3 of the Business and Professiorre Code and my license is in full force and effect. <br /> I License* <br /> I ( Expiration Date: <br /> ( <br /> Dater n <br /> . q '1 Q Contractor r <br /> Title: <br /> Sittnelun: <br /> Printed narne: t 4 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations- (CHECK ALL THAT APPLY) <br /> sation, u <br /> Section 3700 of the aself-insure <br /> (er work forwhichthis Permit provided for by <br /> ermitt Is 18 Uedi <br /> ,�`I have and will maintain workers'eanpenaGtbn ',nsurance,as required by Section 3700 of the Labor Code, <br /> r— for the performance of the work for which this permit is issued. My warkem'compensation insurance <br /> carrier a(n�d policy numbers are: y 1 01 <br /> Carrier: 0.5ko, 1`LQ`al l�ndl ' .. . Policy Number: , ©�Gl�JS s2 <br /> I certify that in the performance of the work for which this permit is issued. I shell not employ any person in <br /> I� any manner ad as to become subject to the workers'compersaton laws of California,and agree that a 1 <br /> should become subject to the workers'compensation proyistons of Section 3700 of the Labor Code I shall <br /> 11 <br /> forthwith comply with those provision, <br /> Date: •q_2, d a-_ $ignaturs: -- <br /> Printed Namr.WARNING.FAILURE TO <br /> SECURECIVIL NEONLLSUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND FIS UP TO ONE DOLLARS <br /> (f1og,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DANAOES AS <br /> PROVIDEC FO SECT 97OaOFTHE LABOR CODE, <br /> I <br /> •I I,-- (stynablre ofC-57 liosnsed suthoAzed repmaentsdvol, <br /> T rW - <br /> hereby authorize 1 t name) rte!! <br /> to sign this San Joaquln County welt Permit Appllcation on my behalf. ! understand idle audwdn#on to valld for <br /> one It 1 year and Is limited to the work Plan dated on the honk P49e of this appdepaon. <br /> L.z5A21 MI - <br />