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12 <br /> San JWRS: <br /> u ty e=nvironmental Health Department Unit IV Well Permit Application Supplemental <br /> JOI3ADD <br /> . 7a4 W' fitit d ' 1 PERMITSRN <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License N: -1 5 I o Exp Date: o i . 3 ; . G e <br /> Date: 10/20/2008 Contractor: Cascade Drilling, Inc <br /> r <br /> Signature: --7 --operations Manger <br /> i <br /> Print Name: Tony Jaramillo <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is Issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Aia &%L � Nc ..4: �yN C Policy Number. Or GWS ? eS31 _ <br /> 1 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 workam' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: G5 . c\ . '�`� _ Signature: <br /> Print Name: Tony Jaramillo <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO F <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO S100,000, IN ADDITION TO THE COST OF COMPENSAPON, INTEREST, <br /> ATTORNEYS FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3"G OF THE LABOR CODE. <br /> / JTHORiZAT(ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION li`{ <br /> I, r Ignature of C=67 licensed authorized representative), <br /> hereby authorize (print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> Mrze>D¢BrI <br /> I <br /> erpzao, , uwr NELL PERM MP I <br /> t <br /> t <br /> 1 <br />