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CASCADEDRILLING • PAGE 02/04 <br /> 107/26/2006 11:23 916639 , rra�e nvux <br /> err[ter[coo [c:ai Ziac ° <br /> San Joaouln County Environmental Health Department Unit IV Well Permit Appllention SUPPiemant <br /> JOB ADDRESS: Ip(if� ' t I)e Ion— PERMIT SR*.. <br /> LICENSED CONTRACTORS DECLARATION (SCD) <br /> I hereby Affirm that I am licensed under the provlslons of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the 6usinsibs and 1professions Code and my license Is In full fume and effect <br /> License g; I r � ' O Expiration Date: `3 <br /> Date: -7 ontradvr. <br /> Signature; <br /> Tine: M a <br /> Printed name:, <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and v-0 maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers compensation Insurance,as required by Section 3700 of(fie Labor Code, <br /> —for the performance of the work for which thio permit is issued. My urorkprs'compensation Insurance <br /> carrier and policy numbers Tore: C <br /> Carrier:Alar —A- I`�a�Id�a'� Policy Number: <br /> I certify that in the performance of the work for which IIN$permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of CaNfomia,and agree that if I <br /> should become subject to the workers'comW9111on provisions of Section 3700 of the Labor Code,I shall <br /> forthwith Comply with those provisions. <br /> Bxplranan Date: r7' — 0-7 Signature:( y ( rJ <br /> PrintedNama: 'CTn,er, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> I AN EMPLOYER TO CRIMINAL PENALTIES AND CML PINGS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ION TO THE COT OF H70a O STHE LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN <br /> AUTHORIZATION FO OTHER THAN C.57 SIGNING PERMIT APPLICATION <br /> (signature ofG87 licensed authorIX20 representative), <br /> Hereby authodae(pant name) Y1 V( i s 1 Yt 1 <br /> W1 S&Cor �W� M pli- I()" <br /> I to sign this San Joaquin County Wolf Pcrmlt Application on my behalf. 1 understand this authorization IR willd for <br /> one lt)Year and is limited to the work plan dated an afe frolft pope Df this appflcatiM <br /> 6 28�OR/MI <br /> an 29.03.001 <br /> 6122Nw <br />