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*TIT M <br />kT174kV1_1:r Z i [OIL,r. <br />JOB ADDRESS: 17100 Murphy Parkway, Lathrop, CA PERMIT SR #: <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: Cascade Dri&g <br />License #: Class A I C57 --93W 1 Q Expiration Date: <br />._!9130117 <br />Signature: —Title: —Regional Manager <br />Print Name: Ralph McGahey —Date: 3124/17 <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 self -insure for workers' compensation, as <br />provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: Ar -F: A.m-e- ri - n Insuranc4-Co. Policy #: - VVI RC49106075 Exp_ Date: I 110, 117 <br />1 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 law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />Signature: 4�� forthwith comply with those provisions. I <br />Print Name: Ralph McGahey <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, 938110 hereby authorize Ralph McGahey <br />E <br />�1 MOM Of AuManad APO <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and Is limit o the work plan dated on the front page of this application. <br />EHD 29-016-23-2015 Site Mitigation Well Pertnit Application <br />