Laserfiche WebLink
65- 0212992 12.33 19166385611 CASCADE DRILLING INC PAGE 63 <br /> U® UL hat! vv.aa r-%A . ai•, OV4 V7./.., YY`.V�• ,......._.:w.,.v - <br /> i*.001 <br /> San Josqutn County Environmental health Sandra,Unit IV WeN Pontilt APPINWlon Supplement <br /> JOB ADDRESS: 3 - t, flFw e, Jgoe - - PERMT SR#'. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I an+Ik:ensed under the provisions of Chapter S(commencing with Sochon 7000)of Division <br /> 3 of the Business and Professions Cope and my license Is In full force and effect. <br /> LCens®C. 717510 Expiratiom Data, 1 /31 /04 <br /> Dazs: 5/02/02 CnA <br /> for Cascade Drilling, Inc_ <br /> Signature-. _ Me: Operations Manager <br /> Printed name. Vera Cha manW� <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty of penury one of the~Mg dsalaratims., (CHECK ALL THAI•APPLY) <br /> I hair*end will maintain a cartiflcate of consent to seff4rnsure for workers'oompensation.as provided for by <br /> ._Section 3700 of the Labor Code,for the performance of the work for which this permit is Wsued. <br /> X I have and wilt maintain workerr compensation insurance,as required by Section 3700 of Via Labor Code, <br /> for Me performance of the work for which this permit is issued, My workers'Compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier• Alaska National Polley Number. 02EWS30531 _ w <br /> I canlfy that in the performance of the work for which this pe Mk it issued,19hal not employ arty paraan lit <br /> any manner so 88 to become subject to the worke=r compensation taws of California,and agree that If I <br /> should beoome subject to the watic W oompensacian provisions of Se ion 3700 of the Labor Code,I shall <br /> forthwmh comply with those provisions. <br /> Bair: 5/02/02 Sig latu 8 <br /> Printed Mama: Verawman <br /> WA,Rt WG-.FAILURE TO s3ECuaE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND 51iALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIeS AND CrflL FMS UP TO ONG HUNt7MD THOUSAND DOLLAR$ <br /> PROVIDED IN ADOMM TD TW COST OF QF THE u OR COMPENSATION. <br /> INTEREST,ATTORNEY'8 FEES$,AND DANAI66 AS <br /> styndurs aW,47 rasntrad autba-1 mpmuenteftvo), <br /> hosbyeUthoriss • Items),_....to sign this San Joaquin County Well Pwmlt Apptiaetlon an my bteftalf. I Wndsretand this authorizatbn la VWW for <br /> one(1)year and Is 0mited to tie work plan dated an the front page W We appllgmtlon. <br /> 6-17-lOoa f NI �� <br />