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08/27/2007 15:20 9166385611 CASCADEDRILLING PAGE 02102 <br /> IOU a f cVY! 14.4J rMA I I tp I 1 00 W-r ,r Gni n kuiuwa r% - <br /> w <br /> 01 <br /> Sen Joaquin County Enviranmantal Health Daparlmant tlntt IV Well ParmltApplicatlon Supplement <br /> .JOB AODRESS:,�a j //. duja .. PERMIT SIO: <br /> A CAN PC a Ca.L /�c"Ad:GL <br /> LICENSED CONTRACTORS DECLARATIONLl CD] <br /> I hereby affirm that I am licensed under the pnwvisions of Chapter 9(commencing with Section 7000)of bMsion <br /> 3 of the Business and P mfessiona Coda and my license is in lull farce and effect: <br /> Licenserr#:_ C'_5-4 -414 510 mvimtlon Data: d 1'/11 1 SOU&_ <br /> Rate:,S 1-7--7 ( 0-7 otar. A 5 f-;4 J .F. Z9 11.1.1A <br /> Am—Me: <br /> Printed name:., �J VIL, - <br /> WORKERS`COMPENSATION DECLARATION <br /> i I neraby affirm undar ponaiq►of penury one cf the following declarattans: (CHECK ONE) <br /> I have and will mafntaln a certificate of consent to sall4Uuura for workers'compensation,as provided for <br /> by Section 3700 at the Labor Code,for the peifarmal'1ca Of thio Mrk for which this permit is issued. <br /> I have and vAll maintain workaw eartlpwLg4on Insurance,as regrllred by Section 3700 of the labor Code, <br /> for the performance of the Work for whlch thls pormlt Is Inued. My workwW Compensation rinsurartes <br /> carrier and policy numbers are: <br /> Carrier: �4�asV . Ana-1_Fallay Number. 0 ? 3Ur 3 � <br /> I certify that In the performance of tho work fbr which this permit Is Issued,I shall not employ any person In <br /> i any manner so as to becoMe sAect to the warners'wmpamtion lows of Calftrnia,and agree Chat if I <br /> sfrould become sublM to the workers'compensation provisions of Sec0a 37 the Labor Code, I shag <br /> forthwith comply with those provi51orm <br /> Expiration Data:5- y d Signature: Q— <br /> Pdnted Naron: rLt 5 if we <br /> WARNING.FA URI;TO SECURE WARS"COtW ENSATION COVERAGE 13 UNLAWFUL$AND SHALL auRJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,00t),l,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORIyIL O FE>~;S,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHO RATION F OTHER THAN G-67 STONING PERMIT APPLICATION <br /> I, aignaWre*IC-87 licansee Auffrarked mprewntfta), <br /> Ifneby authorke(print name) YCX/IZJUI , <br /> to slgn this San Joaquin Cony Wall Permit Applleatton on my behalL I undeniftnd thIa authartmaon Is valld for <br /> one(1)year and W llmltad to this work plan dabad an the 1ent;w9e of M 2ppllcstl6n. <br /> 8,29.02!MI <br /> 150 2M2-Ml <br /> 60104 <br />