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07/08/2003 16:01 19166385611 CASCADE DRILLING.INC PAGE 05 <br /> icat'on Supplament <br /> gen Joaqu€n County Environmelntai Health <br /> RDepartment Unit N Well Permit Apel t� <br /> [JOB ADDRESS: 7 Pf RMIT SRS: <br /> LICENSED CONTRACTORS DECLARATIONL( C.D_} <br /> 3 o the Suslness and (pro esss Code and myer the license is i Chapter <br /> force and ff c9 with <br /> Section 7000)of Division <br /> License : A I - 511,(1. Expiration Date: 211- <br /> Date_ Y o ractor EOA=5 <br /> Signature: Title: <br /> Printed nanwe: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to self4risurs for workefa'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 have and will maintain workers' compensation insurance, as required by Sedlon 3700 of the Labor Code, <br /> for the performance of the work far which this permit is Issued- My work6fV oomPensation insurance <br /> carrier and policy numbers are: <br /> Carder. Policy Number. <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 worker'Compensation laws of California,and agree that if 1 <br /> should become subject to the workers'compensation ions ectidn 3700 of the Labor Code, I shall <br /> forthwith Comply with those provisions. <br /> DaM: Signature: <br /> printed Name: <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 /> PROVIDED,IN FOR ADDITION TO <br /> THE O TOF HE LABOR CODE. INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> UTHORIZ.ATION FOR THE THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ( (signatureotG47 Ilotrnsed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on m behalf. i understand this authorization Is valid for <br /> ons(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br />