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08/19/2003 13:15 19166385 CASCADE DRILLING PAGE 02 <br /> i San.jolquin County Environmental Oeparbgant Unit IV Well Permit AFlpllcationt�Supplement <br /> JOB ADpRESS: /(� ti �2' (T PERMIT SRM.QU 3 2, <br /> LICENSED CONTRACTORS DECLARATION ( � <br /> i hereby 40""that 1 am iloftnW, under the provislans of Chapter 9 (Commencing with Section 70001 of Division <br /> 3 Of the Busttess and Professions Code and my license is in fun force and effect. I <br /> License# _ ( - 22 1-54L-0__Expiration Data- J 31 <br /> Date: ��.�_ a tar: <br /> 1 <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aMrm under penalty of Penury cmc of the following declarations: (CHECK CINE) i <br /> I have and will maintain a certlflcate Of Consent to ee0411eure for worker,'cvmmper nation, as provided f x <br /> by Section 5700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> I have and will maintain workera'compeneatian insurance:, as required by Section '.700 of the Law Cc de, <br /> for the performance of the worK for wtrch this permit Is issued. My workers'eompunaatlon Insurance <br /> rr <br /> caier and policy numbers are: <br /> carrier ),('Bloc n(� Policy Number: <br /> I ceriHy'that m the performance of the work for which this permit Is issued, I Shall not employ any person in I <br /> any manner so as to became subject to the worker!'com ' <br /> p on laws California, and agree that d <br /> should become subject to the workers'compensatbn p df5eqdn 37DO of the Labor Code, I si iall <br /> forthwith od nply with these provisions: <br /> Signature: <br /> Printed Mon r, 1 -- <br /> WARNING:FAILURE TO SECURE WQfWXAS'COMPENSATION COVERAGE IS UNLAWFUL„AND SHALL SUSA.CT <br /> AN EMPLOYER TO CRIMINAL,PCNALTIE3AND Gift FINES UP TO ONE HUNDRED THOU:IAND DOLLARS <br /> (SI 00,0004,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'$PECS,AND DAMAGF,9 i 19 <br /> PROVIDED FOR IN SECTION 7708 OF THE LABOR CODE <br /> AUT NFOR OTHER THAN C-S7 SIGNING PERMIT' APPLICATION <br /> I. _.. _(siemerun OrC-9T Iiaenard ursnardad represerv4e wJr <br /> honey autiwrtre(prknt ame1__ a <br /> to sign We San.Ioacculn County Well Permit Application on my behalf. I understand tMs aui#mn7adoo Is valid f)r <br /> one(1)year and la limited to the work pian dated on the hent pace of this application. I� <br /> a-28.021 MI <br /> LO/?o 3E)'Jd Ia01N001S 39b 8[ttt9460b SE:Et E00S/6f./80 <br />