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,SPE 2J <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application <br /> C Supplemental <br /> JOB ADDRESS: 2151 country club Blvd PERMIT SR# d 5�6 < T/ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 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* 938110 Exp Date: 9/30/2011 <br /> Date: 12/01/2xr009 Contractor: Cascade Drilling, L . P. <br /> Signature' \ �tz= Title: Operations Manager <br /> Print Name: Paul Snelgrove <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 /> X 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: Zurich American policy Number: WC3999959 <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' 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 pro S S. <br /> Exp. Date: 05/01/2010 Signature: t� <br /> Print Name: Paul Snelgrove <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, c (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 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 /> i <br /> 6/29102/N11 <br /> EMD RU1 111W7 WELL PERMIT APP <br />