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CASCADE DRILLINfWC PAGE 03 <br /> 09,118/2003 14:25 1916638i J4.,,,� <br /> 09/10/2003 14:45 91bbt <br /> San Joaquin County Environmental Health Services, Unit IV Wa I Permit Appylootion guPPlemant <br /> JOB ADDRESS: 7z a "' we7's A,�C PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION ( � <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and profession$ Coda and my license is in full force and effect. <br /> License <br /> 7+75th Expiration Date; t/�Ilby <br /> e:� _ <br /> ntra r: <br /> S19nature: _ Title: <br /> Printed name: It n <br /> WORKERS' COMPENSATION DECLARATION <br /> I Hereby affirm under penalty of perjury one of the following dederatlons: (CHECK ALL THAT APPLY) <br /> I nnue and will maintain a osrtiWate of consent to selfdnsuro for workers' Componsattan, as provided for by <br /> Section 37o0 of the Labor Code, for the performance at the work for which the permit k issued. <br /> I have and will maintain workers'Compensulion Insurance,as required by Section 3700 of the Labor Coda, <br /> for the performance of the work for which this permit is 3sued, My workers' compensation inaVreno9 <br /> carrier and policy numbers are <br /> Carhi �'%\ k�% i( Polloy hlumber: <br /> I Certify that in the performance of the work for which this permit is I , 1 snail not employ arty person in <br /> any manner so ae to become eubject to the workure'companaaY+ I of Cailornla, and agree that if I <br /> should become subject to the workers,compensation provision ten 3700 of t bar Code, I shell <br /> forthwith comply with those provisions. <br /> Date _ `— `�_.--��— 9ly^afure. <br /> PAlntad Nan*. <br /> WARNM;FAILURE TO SEG WORKISR8'COMPENSATION COYGRAQE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMa4AL ALTIES AND OIVIL FINES UP TO ONG HUNDRED THOUSAND DOLLARS <br /> (if 00,000.),IN ADDITION TO E COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAIOIAd6e AS <br /> PROVIOEo rOR IN EOTION K OF THE Olt DOVE <br /> (slgnaturs ofci7 licensed■utrioftod ropteaaww"), <br /> hereby euthorMa <br /> no sign this Son Joaq n my Well Permn Application on my"share, 1 understana this authorization to valid for <br /> err(1)yeef and Is limited 1011110 work Wan doled On the front page at this appiicauan, <br /> q-17.2m i all �- <br />