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02/26/2003 13:10 1916636 CASCADE DRILLINWC PAGE 02 <br /> o,;27/00 THU 16:60 FAX 1 91 0330 SEU)K-JM.a.41D14IU .. •-- <br /> FSen Joaquin nCou tty EreAronmental Health Services, Unit IV Wolf Permit Application Supplement <br /> JOIADDRESS: Ro w2sT �asr� sax_ PERMIT SRN: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I or licensed under the provisions of Chapter 9(commeming with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License if: L'S7 7 i J S'a Expiration Dau: 113 i7oy <br /> Date z Contractor: C�srwol On,uwS <br /> Signature: ----- ---- ---Tlth: ID,Jp.Q(1Q r <br /> Printed name: _- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby arlrm under pr nalty of perjury one of the following deolerations: (CHECK ALL THAT APPLY) <br /> I Mw and will mail Win a certificate of consent to self-Insure for workers'componsatlon, as provided for by <br /> T Section 3700 of the Labor Cade, for the pertcmeance of the work for which this permit Is issued. <br /> 1 have and will main twin workers'compensation insurance, as required Dy Soction 3700 of the labor Code. <br /> I for Ins performanct of the work for wnich this permit is Issued. W workers' compensation insurance <br /> carrier and policy n ambers are: 11 <br /> Csrrlar:Y!!N Sk(\ � Irl AI Policy Number: Oa EW6 3 53 1 <br /> I <br /> I certify the:in the f erformance of the work for which this permit is issued. I shall not employ any person in <br /> any manner so as 0 become subject to the workers'compo atlon laws of California,and agree that II I <br /> should become sub act to the workers'compensation pro ' + a Section 3700 of the Labor Code,I shall <br /> forthwith comply wh h those provisions, <br /> Data: cr� _�.� Signature: <br /> Printed Name: V QrQ C *m Cio <br /> WARNING, FAILURE TO.f6CURE WORKERS'COMPENSATION COVFRAOE 18 UNLAWFUL.AND 814ALL SUBJECT <br /> AN EMPLOYER TO CRIM NAL PENALTIES AND CIVIL ONES UP TO ONE HUNDRED TKOUCAND DOLLARS <br /> (5100,000.).IN ADDITION 19 THE COST OF COMPIENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROV1060 FO E ON 7706 OF THE LABOR CODE. <br /> 1, hlQnalurs ofC-ST licensed authorized representsflvel, <br /> hereby suthstize(prin ns me) <br /> to sign this San Joaquin :aunty Well Permit Application on my behalf. I understand tMa authorfratlon is valid for <br /> one(1)year and Is limfter to the work plan dated on the front page of this application. <br /> 5.17-20001 MI <br />