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�r <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS. PERMIT SR#- <br /> LICENSED CONTRACTORS-DECLARATION (LCD) <br /> I hereby affirm that 1 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* C57-717510 Expiration Date 01 -31 -02 <br /> Date 10 12 00 Contractor Cascade Drilling, Inc. <br /> Signature Title Operations Manager <br /> Printed name r Ckiapman <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 /> Section 3700 of 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 <br /> Ca&ier Alaska -Nataonal Ins. Policy Number- 00EWS30531 <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 California, and agree that if I <br /> should become subject to the workers' compensation prove n of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Date 10/12/00 Signature <br /> Printed Name Vera C man <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 IN SECTION 3706 OF THE LABOR CODE <br /> I, (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf 1 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 10) <br />