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08/26/2005 14:24 9166387'711 CASCADEDRILLING PAGE 02/0r0 <br /> �.. <br /> San Joaquin County Environmental Health Department Unit IV Well Pe�rrrtit Application Supplement <br /> JOB ADDRESS: 'ale's 'Savk-LL E.I Z t,CaAo S,„_ PIrRNl1T SR*: r3 �' 2 <br /> LICENSED CONTRACTORS DECLAkATION (LCD <br /> I hereby affirm that I am licensed under the provisions of C11apter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License#: 7 P? -T_ 0 Expiration Date• f"• � Q (�, <br /> Date' ��.`� Contracor. Get S <br /> Signature-, �' Title: S r <br /> Printed name: 1r Z rp, e-' Q rye <br /> WORKERS'COMPENSATION DECLARA-'ION <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 self4risura for workers'compensation,as provided for <br /> by Section 3700 of the-Labor Code,fbc the pel{ormance of the work forwhich this permit is issued. <br /> 1 have and will maintain workers'compensation insurance,as requirad by Section 3700 of the tabor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and pbficy numbers are: <br /> Carrier: if�la$ K,, / Cr)Q f policy Number. d J O s- <br /> ` <br /> 1 Certify that in the performance of the worts for which this permit is issued,I shall not employ an <br /> ee <br /> any manner so as to become subject to the workers'compensation laws of California,and y y person in <br /> t lf*l <br /> should become subject to the workers'compensation provisfa of Section 3700 of the LaborrGode•,tI shall <br /> forthwith comply with those provisions. <br /> Expiration Cote:E ^Q Signature: <br /> Printed!+tame, e-ro`. G <br /> WARNIN(;:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS.UNLAWFUL,AND SHALL SUWP.CT <br /> AN EMPLOYER TO CFUMINAL PENAL17ES AND Cn/IL FINE$UP TO ONE HUNDREDITHOUSM0 DOLLARS <br /> ($900,000.),IN ADDITION TO THE COST OF COMPENSATION;INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PO OY►DED FOR IN SECTION 3706 OF THE LA13OR CODE <br /> AUTHO TI N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, <br /> (Signature ofC-67 licensed authorized representative), <br /> hereby auttl0r3za[print n' e) .�, � �r.� <br /> �oC- u;.sa .t <br /> to elfin this San Joaquin Courrily Well Permit Application on my behalf. I understand thrs.authvrization is valid for ' <br /> One(7)year and IS limited to the work plan dated an the fmnE paged of this application. <br /> 8.29-02/MI <br /> LTM 29.02.001 <br /> 6W,/04 <br />