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G7ib6/260514ypp 9166335611 CASCADEDRILLING PAGE 02/02 <br /> L VG•VC <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: n2g0 ,,t{� �fa� ( PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <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 Ptnfessions Code and my license Is in full force and effaot. <br /> License#: 7 7.5/ 0 3 <br /> q Expiration Date: Z"' l•- n <br /> Date: ? �� �� C ntractor: C 4-t C^07 e__ <br /> Signature: Titin: <br /> Printed name• " <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I hobo and will maintain a Certificate of consent to self;nsure 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 wilt maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this iIs Issued. My workers'compensation insurance <br /> carrier and policy numbers are: / <br /> Carrier: a S ka. Q r a^ q ,Policy Number: 3 l <br /> I certify that in the performance of the work for which this permit is issued. I shall not em Io an <br /> any manner so ns to become subject to the workers'Compensation laws f p y agree p at if I in <br /> should become subject to the workers'compensation provisionSection s a Sec3700 of the Labor nd de, I shall <br /> forthwith comply with those provItIons. <br /> Expiration pate;L (Q Signature: <br /> Printed Name:Azi�_C Jill C4 nn ry e N <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN(EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FrNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 0706 OF THE LAIROR CODE. <br /> AUTH0. TIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> (signature ofC-57 licensed a0thorizod mpm"ntative), <br /> Lherebyxe(printname n til/rt, hn Joaquin County Well permit Application en my behalf, I understand thrs authorization is valid for <br /> d In limited to the work plan dated en the front page of this appOwtlon. <br /> 17I11)29-02.001 <br /> 6U2/04 ' <br />