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03/68Y/f2664 09: 66 19165385F11 CASCADE DRILLINrr INC P:;GE 62 <br /> 6a/OSi2L04 14!44) CLHYIWKUJr 171bOJ� 011 • - -- <br /> San Joequin County Environmental Health Department Unit IV Wall permit Appiloation SUend <br /> JOB ADDRESS: r Sr ERMIT SRN: � 3le <br /> 2 <br /> LICENSED CONTRACTORS DECLARATION (LW <br /> 1 hereby affirm that I am licensed under the proVIWOns Of Chapter 8 (ccmmenanp with Section 7000) of Division <br /> 3 of the 9uelnrss and Profussions Code and my license is In full fares end affect- <br /> ucenae a _ <br /> ] ) 51 Q Expiration Da 1 - 31 - O(o <br /> Con u'tor <br /> Title. <br /> Signature. <br /> Printed name: <br /> i <br /> WORKERS' COMPENSATION DHCLARATION <br /> I hereby affirm under penalty of perjury one of the following declarativns (CHECK ONE) <br /> I neve Ano wig ma ntain ■ cortlllcate of consent to satf-Insure re•Workers comps'"dion• es Pro`r'oad for <br /> by &option 3700 of this Gahnf Code.for Sha performance of the work for which Shia permit is issued <br /> _I neve aria will maipwn wo(KM'componsatlon insurance.all required by Section 3700 of Sha Labor Code, <br /> for the performance of this work for which this permit is Issued. My workers' oompensa'lon InsurnnCe <br /> catrior and policy numbers ere: 1 <br /> Policy Number: � �---- � <br /> Carrier <br /> :�— <br /> I certify that in the performance Of tha work for which this perm t is lsaued. I shall not ornpey any Person IF <br /> any manner W as to bscome subjocl to the workers'compisnsaGon laws of astomia,and agree that If I <br /> should beoorne oublad to the workers'compensation provia a of SqjgW3700 of the Labor Code. I Shall <br /> forthwitn comply <br /> 'w1ith those pfOVleiona. <br /> Date: "23 a Signature; <br /> Printed Name. <br /> AN aMiha; FAILURE <br /> TO CRIMINAL PENTo S&CURE ALTIES AND CM FRW EFINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> NaATjON COVEpAOF 18 UNLAWFUL-AND SHALL UBJECT <br /> PROVID,)) OR N?SECTION 7M 6 COST OF <br /> THE COMPAROR COP ION, INTERE87,ATTORNEY'S pERS,AND DAMAGES AS <br /> AUT RII TION F R Q7NER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1, (olgneturo DfCJ'1 Ilan{ad authorized repYissrntidre]< <br /> horaby authad"(P6 ate) r - <br /> ( to sign this Aon Joaquin County Well <br /> Perm ppcatlon on my behalf. I understand this authorisatlen Is qNd far <br /> oVia(1)year and Is limited to the work pian dated on the front Page of this applleatbn. <br /> S• 11 MI —' <br />