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12/14/2006 18:03 91663856" CASCADEDRILLING PA�rGrrE 02/002 <br /> Iti/r <br /> San Joaquin County Environmental Health Department Unit IV Well Permit ApplientiongSupplement <br /> JOB ADDRESS: /2AJ k-7-usf qr�� l/2_ _ PERMIT SR#: QD��kje-111 r4 <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCCA) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Divlslort <br /> 3 of the Business and Prolesslons Code ana my license Is in full forcA and effect. <br /> I LiC0nc2#: f iiI 1 5 I O () � Expiration Date: <br /> � <br /> Date: 12- ' I _O Contr2ctor:l.V� S� d�� 1/n I I I Vin n <br /> signature: Title: <br /> Printed name: U �� r '"�' L O►v1` <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penelty of perjury one of the following declaratlons: (CHECK ONE) <br /> I have and will maintain a Certificate of corment to self-insure for workers'compensation, as provided for <br /> 1 y Section 3700 of the Labor Code.for the performance of the work for which thli permit Is Issued. <br /> I <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 perrnR in issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: ��K-� `- ti o kla I Policy Number: O�--GtAJ <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 as to become subject to the workers'compensation laws of Cal'ifornla,And agree that if! <br /> should become Subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those pprovlsionc. <br /> 1�7 <br /> Expiration Date: Signature: ,��In <br /> f/n ,/,�Printed Name: f'' �-�tI' +� � <br /> WARNING:FAILURE TO SECURF WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SURJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTOFtNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370C OF THE LABOR CODE. <br /> AUTH RIZATIGIN FOR OTHER THAN C-97 SIGNING PERMIT APPLICATION <br /> 1. (9ignatUrr_ofC-67 licram;ed authorized reprvsentativo), <br /> 1 <br /> hereby authorize(print name) /417— <br /> to sign this San Joaquin county Wmi Permit Application on my behalf. I undamland thig autharl=tlon is vand for <br /> one(1)year and is lirnited to the work plan dated on the ftont page of this application, <br /> e-79-02 l MI <br /> EHD Z9-U Z•AO� <br /> 6122M4 <br />