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12/05/2001 10:05 19166305611 CASCADE DRILLING INC PAGE 01 <br /> 12/05/2001 10:06 20906' 33 FIFTH FLOOR PAGE 01 <br /> San Joaquin County Environmental Health Services,Unit IV Well Pertnit Applieatien $$upplernant <br /> JOB ADDRESS: X701 au1c� t�c�yy� 51l�PERMIT SRi: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with'Rection 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full fares and effect. <br /> If License#: Expiration Date:_ 3 ZO'� <br /> Date: 15" 0 ontfactort 5 C. i' D r f � ! ✓1. <br /> Signature �, w Title: <br /> Printed n e: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pe$ury are of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a oertifloate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> I have and will maintain workers'eompensetion Insurance,as required by Section 3700 of the Labor Code. <br /> for the pefformarae of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers Ore' <br /> Carver: PollcyNulnber: h 1;1 -IS�l-. 1 <br /> I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in <br /> any manner so to 10 become subject 1.0 the workers'collnpensstlOn laws of California,and agree that if I <br /> snOLld become subject to the workers'com nation provisions of Section 3700 of the t-SW Cods, I shall <br /> forthwith comply with those provisions. Of <br /> Date• j` , O ,,,,_,_Signature! `� — <br /> Printed Nan*: <br /> 'I WARNING:FAILURE TO SECURE WORKERS' MPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED N AU ITION TO THE COST or 3709F THE COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> ABOR CODE. <br /> (alpnatuw ofC-S7licensed authorized reprosentaaVe), <br /> I <br /> hereby authorize(print <br /> to sign this Ban Joaquin County Well Pamit Ai*lcsdon on my behalf. I understand this suthorizatlon Is valid for <br /> or*(1)yew and is limited*the work pion dated on the front Page of thl$application. <br /> 6.17-2000!sM <br />