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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> [Division <br /> DDRESS: 8l So S. E� T�ORADt7 s� PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> by affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) Of <br /> 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Exp Date: 9/30/2013 <br /> License#: 938110 <br /> Date: Aril 10, 2013 <br /> Contractor: Cascade urillin L.P. <br /> �� -- Title: General Manager <br /> Signature: <br /> Print Name: Paul Snel rove <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> -insure for workers' comensation, as <br /> provided for by—I have and l Section no3700 oftain a lthe ficatLabor Code,e of for thefperformance of the work por which this <br /> permit is issued. <br /> X 1 have and will maintain workers' compensation insurance, as required by Section worke0 of rs ' <br /> Labor Code, for the performance of the work for which this permit is issued. Myy <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Alaska National Insurance Co. <br /> Policy Number: 12JWS30531 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' <br /> ensationmpovis otns of SectionCalifornia, <br /> of <br /> and agree that if I should become subject th those workers' <br /> compensation <br /> p <br /> the Labor Code, I shall forthwith comply <br /> n/02 <br /> Exp. Date: 12013 — <br /> Signature: <br /> Print Name: Paul Snelgrove <br /> LL SUBJECT AN <br /> YER <br /> WARNING FAILURE CRIMINAL O SECURE <br /> PENALTIES WORKERS'COMPE AND C VIL FINES UP TO $100,OORIN ADD TCOVEGE IS ION\TO THE COSTAOF COMPENSATION, INOTEREST,, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> I, <br /> __.—, � to sign this San Joaquin County Well & Boring Permit <br /> hereby authorize(print name) <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EHD 29-01 05100112 <br />