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10/25/2000 12 33 19165385611 CASCADE DRILLING INC PAGE 0 <br /> • <br /> $4r?fJoaquln County Envlrohcr+ental M021th Servlass, Unit Iv Well Permit Appiicatlort Supplement , <br /> -JOB ADDRESS. 7 467i E im r PERMfT SR#. <br /> LICENSED CONTRACTORS DECLARATION (LCD) ' <br /> thereby affirm that I am licensed under the Grovlslors of Cheoter 9(Commencing witrt Sectcn 7000)of Division <br /> 3 of the Bus nesss and Prefessions Code and my license Is it fill force and effect <br /> License# „ L r11 !ss15 M _ Expfr2tlon Date 31 _0 <br /> I rate � �" —� ontr2ctar CL � ��� � • <br /> Signature TitlepEfua-�[)ms <br /> Prlrited name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following neclaratrCns (CHECK ALL THAT APPLY) <br /> . I have and will mamtoin a certificate of consent to self-Insu a for workers'compensation as provldeo for by <br /> Section 3700 of the Labor Code, for the performance of the work forwhich this permit Is issued <br /> I <br /> I have anC will maintaln workers compensation insurance as required by Section 3700 of fie Laoor Code <br /> for the performance of the work for which this permit Is issued My workers compensation Insurance <br /> carrier and policy numbers a�r��e�� �ns,Carrier U AQ Policy Number 00 53 0 5 3 k <br /> i certify 'hat In the performance of the work for which this permit Is Issued, I shall not employ any person In <br /> aiy manne-so as to become subject to the workers'conpensaWp l9ws of Caldornla and agree that If I <br /> should become subject to eie workers compensation is{ f Section 3700 of the tabor Code, I shah i <br /> forthwith Comply wt'h those provisions <br /> Date- __W7AD--Q0 Signature tt � <br /> Printed Nterne. <br /> t-t <br /> WARMING FAILURE To SE=CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,A140 SHALL SUE JECT <br /> AN EMPLOYER TO CRIMIP[AL PENALTIES AND CIVIL FINES UP TO ONF_ HUNDRED THOUSAND ncx 1 "RR I <br /> ($100.00 k IN AODIT)ON TD THE COST OF COMPENSATION.INTEREST, ATTORNEY'S FEES,AND DAMAOr:S As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE i <br /> 1, a 0 >( y--N Q. n�__ (C-57llcentzed authorized represontatve), hereby <br /> authorize Da 0q, L } e rZ-���- <br /> to s gn this San Joaquin County Walt Permit Application on my behalf I understand this authorirailon is valid for <br /> . one(1)year and is limited 10 the work plan datect'on the front page of this ?pplicatlon <br /> S-17-2000 f MI __^__ <br />