Laserfiche WebLink
U414u/L1317/ ia•,y 9166365611 CASCADEDRILLING <br /> rep. [u. [Vuf I,I IyH.n hr cea ueot v,l ronmant PAGE 02/grU <br /> UJ No, W9 F�0G -40 , 2 <br /> Aft- <br /> San Joaquin Cduntv Environmental Health Department Unit IV Well Permit Application Supplement <br /> J013 ADDRESS_ ;_7 Z-3 U/ �Gi«u/eao�. PERMIT SR#i- f�S06 -78' <br /> —� .. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Pro <br /> ofe <br /> ssions Code and my license Is In full force and effect. <br /> License* = 1 � J 1 0 /'�—Expiration Date- <br /> Date: — Cl — Q Contractor C'oS 6( /�� " <br /> Signature; Title: VP I ( d <br /> Printed name; n vue I Jar-am ( I ( Q <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 warkers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work forwhlch this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performanoe of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: r�// <br /> Carrier:A-10�;Va IV o,-V' 0 r Ct I Policy Number; 0(a <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compenaetion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with thoseprovisions. <br /> Expiration Date: _ 0- 17Signature; <br /> Printed Name; mob <br /> ob ei nam I I ( O <br /> WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT ' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> A�RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit AppUcntlon on my behalf, I understand thin authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8.29-021 Ml <br /> MiD 29.02-001 <br /> AMIN <br />