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05/12/2005 15: 53_ _ 9166365 CASCADEDRILLINf& PAGE 01/02 <br /> A� Q r <br /> San Joaquin County Environmental Hea�ltthh Deportment Unit IV Well Permit Appllcatl Supplement <br /> JOB ADDRESS: � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION L( CDl <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is In full force and effect. <br /> License ff: <br /> C,5-7 7/ 2 -S—/ O Expiration Date: / 0 ,� <br /> Si 12 —O� Contractor: CCSC' Ct '� <br /> Pate: /� �� � <br /> Signature / Title: =�` <br /> � /' 'onr �• <br /> Printed name: ✓ ec, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 /> i <br /> ✓ I havo and will maintain workers'compensation insurance, as required by Section 37GO of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier andel policy numbers are; <br /> Carrier:/7/�S"� / a7�Je-? I Policy Number: OSEIy✓ 5� � <br /> 1 certify that In the performance of the work for which this permit is issued,I shlill not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Caifomia, and agree that if i <br /> should become subject to the workers'compensation provisions of Section 37 0 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 13/' .Signature: 1 �' <br /> Printed Name; ✓ V <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA rUL,AND SHALL SuQJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANP CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO N FOR OTHER THAN C-57 SIGNING PERMIIT APPLICATION <br /> I (signature ofC.57 Iicenid authorized representative), <br /> hereby authorize Ion t name) <br /> to sign this San Joaquin County well Permit Application an my behalf. I understand this authorization is valirJ for <br /> one(9)year and is limited to the work plan dated on the front page of this application. <br /> 6.29-021 MI <br /> EHD as.na.ne i <br /> craaroa <br /> 05/12/2005 THU 15:51 [TX/RX NO 56661 Q001 <br />