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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS PERMIT SR#• i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License# C57-71 7510 Expiration Date 01 /31 /02 <br /> Date 10/ 12/00 Contractor Cascade Drilling, Tnc. <br /> Signature Title Operations Manager <br /> Printed name Vera Chapman <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers compensation, as-provided for by <br /> Sedtion 3700 bf the Labor Code for the performance of the work for which this permit is issued-- -- - - - <br /> X 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 are T = <br /> Carrier Alaska National Ins. Policy Number OOEWS30531 <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 Idws of California, and agree that if I <br /> should become subject to the workers' compensation provision of S ction 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Date. 1 0/12/00 Signature <br /> Printed Name Vera LM&mn� <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <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,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE <br /> 1. (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf I understand this authorization is valid for <br /> one (1)year and is limited to the work plan dated on the front page of this application <br />