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10124/200S 15 17 19165385611 <br /> CASCADE DRILLING INC <br /> FPO-; GEr%E-R-RYPt4 ltfC, PAGE 02 <br /> PHONE T.�Q �2& b3! ]3]7 Gct 24 27$0 11,560 F2 <br /> San Joaquin County Environmental Fteeith Sarvices, Unit IV Well Ponnit Application supplement <br /> J013 ADDRESS: 'q z � C— ,I?���Y PERMIT 5R*: Q C 3 <br /> ( � , c-I-iI P-�5 - c4 k wazCa <br /> LICENSED CONTRACTORS DECLAIRM-noN (LM <br /> t4 I hereby affirm that I am hcea*ed under the nrowcsiont of Chapter 9(commencing with Secdon 7000)of Orvf wn <br /> 3 of the Busirssss Una Profmion*Cove and my Ikfenase 4 in till fond and aflbct. <br /> 5 <br /> lccettsa ,, <br /> C57-7; 7 510- . ^� F�eplraacn t3tte f <br /> Date 7 Contractor _ Cascade QrxL11nS. Zne. <br /> Signatures TMs• _ _92er-tions Manager <br /> Printed riame. Chapman <br /> WO)RKERS' COMPlENSAYlON DECLARATION <br /> t hemoy elfltrm under penairy of perjury one of In*faliowwv declarations (CHUCK ALL THAT APPLY) <br /> I have and will maintain p cartiftcate of=Sent to Beit-Inavrf for Workers compensaLvn. as pr*,ndod for by <br /> Secuan 3700 of tho Lzti or Cotte for the perforrnenas of trie worts for which Otte permtt rs Issued <br /> X I have and will maintain workers'COMPermabOn rMISUMF100. as MWO-Od by SQCdon 3700 of Mik Lobor Code, <br /> + for the permrmancs of the work for whicri M3 permit is ssat+ed My workets`Compsthsatton insurance <br /> ra.'ner and policy nurnpam are <br /> Cotner. _ Alaska NaitiQrtal Ins. Policy Number ODEWS30531 <br /> i teddy that In trite performance of the work for whtctl this perrmt is Issued I shall not employ any pareon In <br /> any mann*r so as to bocorne aubpect to the wortters' =Moensatron laws.of California,and agree that If I <br /> should becetre sub)*Ct to the wonters'ccirnpariso:an f SecUon 3700 of the Labor Cods,t shell <br /> roMvAth comply ward tnose pi-matorhs <br /> Date. 10112/00 <br /> siprfatur• <br /> PKated Naas@: Vera r" m n <br /> WARMING FAILURE TO SICURt WOMMM'OOMPONSATION COVIRAGP IS UNLAWFUL.AND$HALL$WUCCT <br /> Ale aMpLvyiRM TG CMIAINAL PENALTIEN ANC CIVIL Floes VP TO ONE HUMORED THOUSAMO DOULARS <br /> (1100,a0011,IM^DCN ION TO Trio COST OF CCMPIENSA-110N,INTERMS'r'.A{"TORNtl1 S FEW&AMC DAMAGES AS <br /> PROViDIrQ FOR lM 8B=ON 3700 OF THE LAROK COM <br /> I. �zCg& Gt �C•3t ilra+hsfd istafhorizad ree►sseneat#v+i.heh�bfr <br /> to 9ISn this San Joaquin County Yihll Pemit Applle*Uon on my behalf. I undaeh Und We.aluhoritWo h Is vr"for <br /> one 91 MOMW and Is I1MW to Via work plart ditad an ttha tront psof this s Istadon <br />