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03/19/2004 11:00 19166^"5611 CASCADE DRILLT— INC PAGE 02 <br /> F !an )osquln County EnVlrortrnarttal Health Sawioaa. Unit IV well Permit APPIICatIOn Supplanxnt <br /> JOB ADDREs�S: PERMlT SRN: <br /> 5Yoc k.^A) , CA <br /> LICENSED CONTRACTORS DECLARATIONISL <br /> I hereby affirm that I am it "ed under the provision&Of IS In Chapter 9 (0�awith Section 7000)of Dlvlsion <br /> 3 of the Busing"and Professions Cod!pnd mY <br /> '� Expiration Date: I ` <br /> License 0! .. <br /> t 6 ' CO factor: t <br /> Date: [ � <br /> Signature' <br /> Prinled nartte, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm udder penalty of perjury ono of the fdl*Mng declarations; (CHECK ALL THAT"PLY) <br /> I ha�e and will maintain a cgrtifioate of consent to fffor <br /> Section 3700 d**Labor Coda for the perfontta eof the work for whth permit is Provided for by <br /> issued. <br /> I have and will rnaWdan workers'compensation insurance, as raqusred DY Section 3700 oftlion e Labor anoo�e <br /> for the padormQ11oe of the Work for which this parmtt is issued. My worker'oom � <br /> pe^ <br /> carrier nnzml=u�— <br /> numbs <br /> Corder: Polky Number; �16Q��y� <br /> I oertity that in the performance of the work for which this permit is Issued.I shad not ernpk►y any per' in <br /> any manner so a3 to become subject to trio workers•oompanSatian law s of Of Calms ip»�bo Cade. 1 shall <br /> should become surfed.to the <br /> pro s.compensation pro ' <br /> forthwkh oompiy 1 <br /> SU - t3lgnatuw.. <br /> PriM.d Name. <br /> WARNING:FAILURE TO$MUMS WORKf[FltY'CO1iMPENSATION COVERA"IS UNLAWIFUL,AND SMALL&USJECT <br /> AN EMMFG0v=To CRIMINAL PENALTIES IND CIVIL FINES UP TO ONE HUNORED THOUSAND DOLLARS <br /> PRC "'))�IN A10 TO OF YIIE LA6oti CODE�x,tNTEf1E>ST,ATr+OftN11EY's Filsls,A1t0 DAMlalii�AS <br /> f, (slynature om-ST Rearmed MuthOrlsed mpresont"ve), <br /> hereby authorfre(print no ) � <br /> to sign this San JoRrtuin County WON Pffmn/rpplkfatlon on.tmy �. I understand this suthariWAGK Is valid for <br /> ora(t)year and is Nmitsd ZO the work plan dated on the front page of this spptloation• <br /> 5.17'�200e/Mit <br /> 7.A/Z0 39dd iyG73S 6Eb0L969L6 Eb 60 b00L/6t/�4� <br />