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:10/16/2007 10:05 916634 CASCADEDRILLING PAGE 02/02 <br />San Joaquin <br />Mafth Department Unlit TV WeR Permit <br />JOB ADDRESS". PERMIT SRN, <br />'LICENSED CONTRACTORS DECLARATION! (L <br />I hereby affirm that I am licensed under the provisions of chapter 9 (commencing with section 7000) of Division <br />of the Susinessoand prof6sslons Code and MY license i$ in fun force and effect. <br />—09 <br />License 0: -7 1-7 5) 0: Expiraftn Date. <br />07 1DP-ILL-IN4�'ONc� <br />Date: I Q <br />Title-. <br />kk <br />P, r -A t L, L- 0 <br />Printed name: 0 <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty 6f perjury one of the following decktirations: (CHECK ONIE) <br />I have and will maintain 6 certiftate of consent to seff-insure lbrworkers'compensabon, a$ provided for <br />by Section 3700 of the Labor Code, for the peribmmFice of the work forwhich this pet: * is issued. <br />Vol, <br />I have and will maintain workeW compensation insurance, as required by Section 37W of the Labor Code, <br />for the performance otihe work forwhich this permit is issued. my workers, co , mPen#ation insurance . <br />carrier and policy numbers are. <br />0-7 31015a <br />01 6 0 -N & . 6 Pcilley f4umber. - <br />1 certify that in the perroff.nartoe;ol he work for which this permit Is Issued, I shelf not employ any person in <br />any manner to as to become subi:ct to the workers' compensation Ism Of Catilbm*. and agree; that if I <br />should b000me suNed to the v4orkers'dompansatioh provisions of Section 3700 of the Labor Code, I Shall <br />forthwith comply with tho,ge p KOS. <br />Expiration Date: 0 <br />-7 A <br />WARNING: FAILURE To SECURE WORKERSY'rOMPENSATION COVERAGE IS UNLAVIFULJAND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINALPENALAES AND CW FINES Up TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO TELE COST OF COMPENSATION, INTEREST, AT roRNErS FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3*100 00 7!HE LABOR CODE <br />AUTHORIZATION FOR bMER THAN C-57 SIGNING PERMIT APPLICATION <br />__(signature &C-57 licensed authorized mWesentative), <br />hereby authorize (print <br />to sign this San Joaquin C6un�ty Well ftrmlt Appikarlon on my behalf. I understand Otis <br />one (1) year and is limited to the work g4an domed on the Ilront page of this application. <br />9-20-021 MI <br />MID 29-02-001 <br />6122104 , <br />is valid for <br />