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'31 <br /> 0906/2005 14:-0 9166385611 CASCADEDRILLING PAGE 02/02 <br /> San Joaquin County Environmental Health Department Unit IV Wali Permit Appllcatlon SupplOment <br /> JOBADDRESS. LO`ftf- LLXI PERMIT 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 Hall force and effect, <br /> Expiration Date: / 3/— 0 r,, <br /> Gare: C ntractor: C vl L /� <br /> Signature: Title: l�Q,.0 ci f <br /> Printed Haute: �G�� �'�� —����� <br /> WORKERS' COMPENSATION DECLARATION y <br /> I hereby affirm under penalty of perjury One of the following declarations: (CHECK ONE) <br /> I halm And will maintain n certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance Of the work for which this permit is issued. <br /> I have and will maintain workers'compensatfon insurance,as required by$eotion 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:&fit S ka d r d^ q �Policy Number: LQtA/C> 05-13 l <br /> I certlrY that in the performance of the work for which this permit is issued. I shall not employ an <br /> any manner so as to become subject to the workers'corm ensatlon la f p y agree penton in <br /> that if I <br /> should become subject to the workers'compensatfon provsldns o Section 3700 Of the tabor and de,I shall <br /> forthwith comply with those pmVlslOns. <br /> Expiration Date. ( Signature:__ <br /> Prihted Name: _C [ )q <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANP DAMAGES AS <br /> PROVIDED FOR IN SECTION 0706 OF THE LABOR CODE. <br /> AUTHO TIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> f. <br /> �(signatura ofC-57 rlcensed authorizod mpresentative), <br /> hereby authorize(print name <br /> to sign this San Joaquin County Well Permit Application on my behalf 1 understand this authorization is valid for ' <br /> ono(1)year and Ir.Betted to the work plan dated an the front page of this apprfcatlon. <br /> 8.20.02/MI <br /> e ID2.9.02-ori <br /> er2zroa <br />