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F.5/21/2000 14.29 19166985611 CASCADE DRILLING INC PAGE 02 <br /> 051-'21 R3 14,614A5 FAX 1 9' 1303 0430 Z)ZLUK-aeLAAAGNIU �- -- <br /> Sen Joaquin County Environmental Health SerAces,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT $RAM; <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that 1 am lioensed under the provisions of Chapter 9(commencing with Section t000)of Oivision <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Lirense 0. CS7 11 r7 5 [ 0 Expiration Date' -1 - 31 — o'1 <br /> Date:--5 - a I-O ntraotor:. �1 <br /> Signature. Title: {� <br /> Printed nems: �(N � �J1`� <br /> WORKERS'COMPENSATION DECLAJ;tATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> .,I have and will maintain a certificate of consent to self-insure for workers'compensation,as provloed for by <br /> Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. <br /> _I have and 011 maintain workers'compensation insurance. as required by Section 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 <br /> Oicycnumbers�ar(e, (� <br /> Carrier: t ] Q,7k� t4 A, -on a Iftlicy Number. <br /> _I cartify that in the performanoe of the work for which this permit Is Issued, I small not employ any person in <br /> any manner so as to become subject to the woo ra'oornpenee ion laws of California,and agree that 01 <br /> should become subjeot to the workers'compenSaWrl provis of tion 3700 of the Labor Coda, I shrill <br /> lorthwtth comply with those provisions. <br /> - - <br /> Date: �.Z Signature: <br /> Printed Name; \,6 co, ("tAL rna to <br /> WARNING:f AiLuf%Z TO 3CCURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SusJ®CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.).IN ADDITION TO TkE COST OF COIAPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES As <br /> PROVIDED FOR 1 EC N 3706 OF THE LA9OR CODE. <br /> 1� (alpnatu ••ofc-67 licensed authorised representative), <br /> hereby authortse(prtetnaeta k- ===-- --- ----_ <br /> to sign this San Joaquin County We/Permit Ap astion on my behalf. I understand this authorfaatioe Is wild for <br /> one(1)year and is timftd to the work plan dosed an tM front page Of this apQlication- <br /> Irf7-20001 ul <br /> s <br />