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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1423 Bradford Street PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: Cascade Drilling <br /> License M 938110 �7 Expiration Date: 9130119 <br /> Signature: Title: Project Manager <br /> Print Name: Kenneth B.Cook Date: 8/19119 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> i have and will maintain a certificate of consent to self-insure for workers'compensation,as <br /> E3 provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> IN Labor Code,for the performance of the work for which this permit is issued.My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: On File Policy#: Exp.Date: <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 law of California,and agree that if I <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Signature: /�oitx¢fl�/j. 46 <br /> Print Name: Kenneth B.Cook <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Kenneth B.Cook ,hereby authorize P <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization Is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29-018-1-2017 Site Miliga0on WelgaoNtg Permit Application <br />