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s 08/04/2005 10:43 9916638561✓ � CASCADEDRILLING -. PAGE 02/04 <br /> „ .ra„�� �,,��,,. , ,�,imcniai <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: .57'PcH- i7r1f 0 R PFRMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 Professions Code and my license is in full force and effect. <br /> UcLnse ff: CL15-1 -11 7 5( 0 EVirafiun Date:.__ 1 -O <br /> bate: - -0 Contractor `j i <br /> Ino- <br /> Signature; Tiue: <br /> Printed name: 0- <br /> WORKERS”COMPENSATION DECLARATION <br /> I <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certlfieato of consent to 1seH-insure for workers'compensation.at provided for <br /> by Section 3700 of the Labor Codu,for the performance of the work for which this permit is issued, <br /> XI have and will maintain workers'Compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the psr"ance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier,�,� {a 18[�()� Policy Number. <br /> I certify that In the perfbrmance 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'compensation 4prmovisionsf Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Datta:.r,>- -I - 0(v Signature <br /> Printed Name: Q <br /> WARNING;FAILURE TO SECURE WORKERS'COMFIENSATION 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 AODIT1DN TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORI 10 OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Q (signature of"7 liannsed authorized miumseniative), <br /> herebyauthorize(print nam )__,8 t / l� <br /> I to sign this San Joaquin County Welt Penult Application on my behalf. I understand this authorizatian Is valid for <br /> Otte(1)year and is limited to the work plan datod an the front pegs nt this appn oon. <br /> ti <br /> &2&021 MI <br /> EFID25-0 .001 <br /> &72M <br />