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2011 -„05- 18 12:50 CASCADEiRILLING 19166385611 2099836960 P 2/2 <br /> t9 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> o626DZ <br /> JOB ADDRESS: igvts� r.4 Trow%6 PERMIT SR# <br /> LICENSED-.CONTRACTORS DECLARATION (LCD) <br /> i <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: E xp Date: C1 ' 0 1 1 ) <br /> Date: ^ZD I ( Contractor. ��it �C/.G(L� D V1 I✓) L h <br /> Signature, Title: 0 I I00 i M (I YI f GI Ei1� <br /> Print Name: ['I�eyL-'A- I I h V pye-�- <br /> WORKERS' 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 /> 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:A1/A/-,�rA- N(A-'okilAJ I1`11-elAff m Pa PollcyNumber: <br /> CU M F^/` <br /> I certify that In the performance of the work for whicK 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, <br /> and agree that if I should become subject t0 worke ompensat' tovisions of Section 3700 of <br /> the Labor Code, I shall forthwith com ply with or' <br /> pro isior� <br /> Exp. Date: 10 UZ III Signature. --c_ <br /> Print Name: 1�. LAS- C' I i'oye---- <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 /> ARI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, cam. (signature of C-57 Ilcensed authorized representative), <br /> her by authorize (prin o);50 SOAfibft , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> CH0294+ 07128'10 WELL PERMIT MP <br />