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09/06/2005__14:00 9166385611 CASCADEDRILLING PAGE <br /> " L �02/02 <br /> Joaquin County Environmental Health Department Unit IV Well Permit Application SupplementF.-San <br /> B ADDRESS: (�2 � SC-tIi'II}wLt �a1 PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION {LCDs <br /> I hereby affirm that 1 em licensed under the provisions of Chapter 9(commencing wllh Section 7000)of Division <br /> 3 Of the Business and Professions Code and my license Is in full force and effect. <br /> I License#; 3 <br /> Expiration Date; "- (D <br /> pate: l`t l' C. �'O.$~� Contractor: pr'r �� n <br /> I. <br /> Signature: Titin; ©Q—r q f <br /> Printed name: rG�� G �/ <br /> WORKERS'COMPENSATION DECLARATION _ <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of Consent to self4nsure for workers'componsation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> I have and wilt ms intain workers'compensation insurance,as required by Section 370 of the Labor Coda, <br /> for the partcrmance of the work for which this permit Is Issued. My workers'compensation insurance <br /> carrier and policy n <br /> /umbers are: / <br /> Carrier: Gt S Ka d r an q policy Number; OS`j�V✓S�a�3 Ir <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ an <br /> any manner so as to become subject to the workers' P Y agree person in <br /> that if I <br /> should become subject to the workers'compensat on pro�s;onstianSecti of 3700 of the Labor alifornia,and de, I shall <br /> forthwith COmply with those provisions. <br /> Expiration pate: ^ 3 ^d(Q Signature:,,,__ <br /> Printed Name:Y CSC `tom 1 C} g.y1 ,n <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS <br /> UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($f00,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 07OG OF THE LABOR CODE. <br /> AD�TIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> .-.._(signaturd ofC-57 licensed authorized ropresentative), <br /> hereby authorize(print name n <br /> to sign this San Joaquin County Wen Permit Application on my behaIr I understand this authorization is valld for <br /> ona(1)year and ir.limited to the work plan dated on the front page of this appncatlon. <br /> 8.29.021 Mt <br /> HRD 28.02.001 <br /> e/222va <br />