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1g414/2002 10:35 19166385611 CASCADE DRILLING INC PAGE 02 <br /> R <br /> !x/,111120[52 1F_t:25 2 P/?1118 PGE 3TDCKTO1`4 FAGE 01/01 <br /> I San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT OR$,--,— {{ <br /> LICENSED CONTRACTORS DECLARATION (LC„� !� <br /> I hereby aif'rrr,, shat I aril I;censed under the proves ons of Chapter 9 (commencing with 5ectian 7400)of pivisian <br /> j 3 of th4D Uvatness and Profeselans Code and my license is in fu'I force rind s¢fec*- <br /> Ucerse 4: - J -- Expiration Date: <br /> Dale, ontractor; <br /> r <br /> 9-- <br /> Signature' -� ---Tli)e: 1 <br /> 4srrnted name: <br /> r <br /> WOFWERW COMPENSATION DECLARATION l <br /> heretby aff,rrn under penalty of perjury ore of the followirg declarations' (CHECK ONE) <br /> I have and will ma ntWn a certifirrate of consent to self-insure for workers'compentso0on, as provided for <br /> oyf Secnan 3740 of the Lebor 000x, for the perfprwance of the work for`which this permit is iasLrad. <br /> rave anti will rnaintriri workers'compt"Isallpn Insurance,as required by Section 3740 of the L000r Code, <br /> tol the performarce or the work for which lhi,s permit is issued. My worker's'comperibetian insurance <br /> ca'rier ar.d policy mirnbv�s are: <br /> Carrier: _ 5 , - Policy Number; — <br /> I cerlify that�n the performance of the work for which this permit is !;suacl. I sha!I not employ any person in <br /> any manner so as to become subject to il?e workers'cemper,sailon laws` of California, and agree that if I <br /> 5,3,>uf3 become sibject to pie workers'co npensatior pr elan f gest on 3700 of the i~abor Code, I she <br /> forthwi:h comply with those provisions. <br /> Printed Name. Y-QL06.- - <br /> I WARNING.FAILURE TO SECURE WORKERS'COMF'ENSAT'ION CovERAGg IS VNLAMVFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNPRED TMOUSAND DOLLARS <br /> ($1100,00) %OR IIN ADDITION CTITO 14E COST <br /> TMEOF O 0R CODEION,IN�IrR IST,AT70RNFiY'S FEES,D►lVa DAMAGES 14$ <br /> DED <br /> AUTHORIZATION FOR OTM THAN C•51 SIGNING PERMIT APPLICATION <br /> p 1 Q (sl+�nelture ofc 57 ilcanlcad aultiorlxed repro rei�taUY ) <br /> �a- c � CL <br /> hnwby authoelzo(print.maitre)�to sign thla San Jnaquirt County Well Permit Application on MY behalf. I tmcreretand this authorixanca Is velto for <br /> one(1)year and is Ilrrdted to t"Work pion dstad on this}Tort 0894 of tWa application. <br />