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05/23/2008 12:34 9166385 1 CASCADEDRILLIN PAGE 02/02 <br />05/20/2008 08:23 71496 2 MILLER MUUKb rtwat �� <br />San Joaquin County Envirwmrientalt Heee�ljfih Department Unit iV Wali Permit Application Supplemental <br />JOB ADD' „ Y NRIM SR <br />pALK al <br />�! <br />I hereby affirm that i am licensed Lander tbd provisions of Chapter 9 (commencing wRh Section 7000) of <br />Division 3 of the Business and Frofesslons Code and my license is In full form and effect. <br />License 9: Exn Date: i 31 (C5 <br />Print i <br />ftletor: <br />Title:v 012 <br />w IS•1 • <br />i hereby affirm under penalty of pejury one of the folk*ng deolarations. (check ane) <br />i have and will maintain a certificate of consent to self -insure for workers' compensation, as <br />provided for by section 9700 of the labor Code, for ft performance of the work for which this <br />permit is Issued, <br />I have and will maiuritain workem'compensation Insurance, as requires by Sermon 3700 of the <br />Labor Cads, for the Perform nee of the work for which this permit is issued. My workers' <br />compensation Insurance cater and policy numbers are: <br />Carrier: t IC k-0. t� ►Ctt1t � „ Policy Number , C Eu)s 345 3 1 -- <br />I certify that in the performance of the work for which this permit: is issued, I shall not employ arty <br />pert In any manner so as to become subject to the work compensation law of California, and <br />agree that If I should become subject to workers, oomperift0on provir <br />of Section 3700 of the <br />Labor. Code, l shall forthwith comply w with those p Biro . <br />■, r <br />Print Nacre: <br />WARNINO FMILdiRS To SECURE RS' COMPENSATM covERAcE IS UNLAWFUL, AND �G4LL SUBJECT iii EMPLOYER TO <br />MKNAL PECMLNALTiRG AND CL FINES UP TO $100,00% IN IMDOMON TO THE COST Ok COMPENGATiON, INTEREST. <br />ATrORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3YO6 OF THE UU5bR CON. <br />I <br />AU�H RI ON FOR OpiI R lGNINO PERirr APPi cA-nON <br />(sfignatu aFCd+ 7licensed itithorized repress ), <br />hereby a Whoriae (print name) � _ � � . to <br />sigh this $an JON19117 county Verso permit Appri*Won on my behalf. I and <br />f*f Or@ year Irnd is itlMted to the work plain dated an the front pap or this <br />this authodmition is valid <br />WELL PERMT A 9P <br />