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11/F7bIZUU4 1L:5L ylbb:,b,')bil CASCADEDRILLING PAGE 02/02 <br /> 11108/2004 11:25 9160 _1430 SECQF, HALME U2/uz <br /> v %Nit <br /> San Jonquln County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Z �t�©1 � U"r'� �► PERMIT SR#: <br /> - , CA <br /> LICENSED CONTRACTORS DECLARATION ( GD <br /> I hereby affirm that I am licensed under the provioions of Chapter 9 (commencing with Section 1000)of Division <br /> 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License ai: i _, Expiratlon l? te: IS I <br /> Date. I Contractor: Q C� _ fl - <br /> Signature: Title;Q c� <br /> Printed name: xfl Yl <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under pemolty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I havep_and will maintain a certificate of consent to self-insure for workers'compensatlon, as provided 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 will 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 policy numbers <br /> ,1are- <br /> Carrier: G1�1 C me (Policy Number:QH GLA) <br /> I certify that In the performance of the work for which this permit is issued,t shall not employ any person in <br /> any manner so as to become subject to the workers'compenwtion laws of Californla,and agree that If I <br /> should become subject to the workers'compensation provi ' s t Sectio 3700 of the labor Code, I shall <br /> forthwith eomply with those provisions. <br /> Dates: -Signature: <br /> Printed Name: <br /> WARNINGc FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL,SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THIO COST OF COMPENSATIOW,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN [ON 706 OF THE LABOR CODE, <br /> I, (signature of <br /> 0-67 licensed authorind mprPs@nta#Ivy ), <br /> herebyautherize�(print name) "�d 0— t n C_ <br /> r ' <br /> to sign this San Joaquin County Weli ft.Mit A.ppfleation on my behalf. I undorstand thit,authorization is valid for <br /> one(1)year and is limited to the work plan darted an the front page of this applicidlon. <br /> 5-17.2000 f MI <br />