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111 U(I ZrA30 I 4d yl bbJd!3b1 i CASCADEDRILLING PAGE 02/04 <br /> San-Joaquin County—Env-ir'onMental Health Department Unit IV�?—Veli P---- <br /> "I? - – ermit Application SuPillement <br /> JOB ADDRESS: PERMIT SR#,, <br /> FSa, P01181iOn SUPPfilmen <br /> JOB , <br /> LICENSED CONTRACTORS DECLARATION (.!,CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and'Professions Code and my license is in full force and effect. <br /> License 9-— C5 7 -- -7 1-7 51 �iration Date: <br /> Date,A—U-7 (0Contra r: <br /> r11--, <br /> Signature: <br /> Title: <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 will maintain a certificate of consent to salf-Frisure for workers'compensation, as provided for <br /> 46by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> 1 have and will maintain workers'compensation In.surance,as requ"d by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued, My workers'compensation insurance <br /> carrier and Policy numbers are: <br /> Carrier, Policy Number., <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 laws Of California, and agree that if I <br /> should became subject to the workers'compensation provisions of Sectio 700 of,the Libor Code, I shall <br /> forthwith comply with those provisions. <br /> Expimtlo <br /> n bate:l� Ignature, <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS,COMPENSATION COVIaRA015 IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND 6OLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,AYTORNUrS FEES,ANb DAMAGeS AS <br /> PROVIDED FOR IN SECTION 3708 OF 71-jE LABOR CODE. <br /> U11 of, Labor Code, I shall <br /> AUTH! RIZA'TnION 0 0 ,_,f,THAN C-57 SIGNING PERMIT APPL16ATION <br /> (signature ofC-67 lioensod authorized representative), <br /> hereby authorize(print narnaos) <br /> .to sign this San JOaguin County Well Permit Application on my behalf. I undOrstand this authorization is valid for <br /> one(1)yoar and is limited to the work plan dated on the front page of this application. <br /> 1 <br /> 9-29-021 MI <br /> EMD 29-07-f)Q1 <br />