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EHD 29-01 07/20110 WELL PERMIT APP <br /> Sea Anniqlmin County Environmental Health Department <br /> WELL& DORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am No us •.iuiller the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business aro &-*ftss+ons Code and my license is in full force and effect. <br /> License#: 938110 Exp Date: September 30, 2103 <br /> Date: August 29, 2013 Contractor: Cascade Drilling L.P. <br /> Signature: �'� C Title: General Manager <br /> Print Name: Paul Snelgrove <br /> +SIt111 4IM' COMPENSATION DECLARATION <br /> I hereby affirm under pel+ ., one of the following declarations: (check one) <br /> I have and wir - arcate of consent to self-insure for workers' compensation, as <br /> provided for b► _ -+ + the Labor Code, for the performance of the work for which this <br /> permit is issuwa <br /> X I have and wit compensation insurance, as required by Section 3700 of the <br /> Labor Code,fo M of the work for which this permit is issued. My workers' <br /> compensation oam-•.r...Y r-rr and policy numbers are: <br /> Carrier: Alaska National Insurance Co. Policy Number: 12JWS30531 <br /> I certify that in so r of the work for which this permit is issued, I shall not employ any <br /> person in any nrpow n ar m become subject to the workers' compensation law of California, and <br /> agree that If 191 rr+wa subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I Burr wrs. xlmply with those provisions. <br /> Exp. Date: October 20, 2013 Signature: 1`x � <br /> Print Name: Paul Snelgrove <br /> WARNING:FAILURE TO SECLM� cOWENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTM dMOM 4OWS UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEEL,Ar 2611111111 AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION POR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Q k�__ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print nams) Abe Northup ,to <br /> sign this San Joaquin County Wse d Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limked to the work plan dated on the front page of this application. <br /> EHO 29-01 0720110 WELL PERMIT APP <br />