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03/01/2005 14:42 9166380 CASCADEDRILLING PAGE 02/02 <br /> reo co UO ue: lup wooers nx GnaxsOrl `Jib- u-ulUti P. <br /> San,ioaquln countyEnvil"Mmantai Health Drpattrnent Unit IV Weil Permit Application Supplement <br /> JOB AWRESS1.2 6 . E- ' P i N cS7r Lon.'-Cn. PERMIT SR#' <br /> LICENSED CON'T'RACTORS DECLARAT'ON (1.9 <br /> 1 hereby affirm that I am licensed under the provieforn of Chapter 9(commencing with Section 7600)of division <br /> 3 of the Business and Profesalons Code and my license Is in WV force and effecL <br /> Llcenae if: C5 -2' 1 ) L-(� - Expiration Date: - <br /> Date: 2)-' i Contractor: R /� <br /> )Egnaturt r. Iitie• 1 <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARA71ON <br /> hemby affirm under penefty Of pefjury one of the following declarations: (CHECK ALL TRAT APPLY) <br /> i ha`re end will maintain a certificate of conserit to selfansure for workers'opinpensRtlon,as provided for by <br /> Section 3700 oFthe Labor Gale.for the performance of the work for which this permit Is Issued. <br /> I have anti will maintain workers'compensedon Insurance,as required by Section 3700 of the Labor Co <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numblers are. <br /> Carrier. -Poticy Number: C)4t x ,5s2-Q.'� ) <br /> I cerfffy that in tho performance of ft*,M*fbr»trach this perrnft IS 4Wdd, f shall not employ any person M <br /> any manner so as to become subject to the workers'aompeneation laws of California,and agree that if 1 <br /> tio <br /> should become subject to the workers'compensan pro ' - s of Section 3700 of the Labor Code, I shall <br /> Idrthwith comply with those provisions. <br /> tate' �..a-1-0S Slghatore' <br /> Printed Nome: <br /> WARNING:FAILURE TO SI?CUFIE iIVORKMS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND GIVIL FINES UP TO ONE HUNDRED T)MSANO DOLLARS <br /> (5100,1000),IN A130MGM TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FO N 8706 OF THE LABOR CODC. <br /> 1, (signature ofa•07licensed autlwtUad tapreamtative), <br /> )terebr authodre UNI t name) 13o b /1 14-4---) d 5 on -to sign this San Joaquin Coordy Woll PermItAppiiaatien an my beti*M 1 understand this authedamUcrt is valid for <br /> ort(1)ynw and is Undfed to flra•work plan gROtd an the ftvnt Palle of this applieauon. <br /> 1.23.02 r Mr <br />