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09/051'2002 16:56 19166385611 CASCADE DRILLING INC PAGE 02 <br />05/1712091 19: 3G 2094693433 FIFTH FLOOR PAGE 02 <br />rrZ14z,tr( L-7UI JV, Wc,� <br />San Jod<uin County Environmental Health Serykoo, Unit 1V Well Permit Applicatlo?rt Supplement <br />JOB ADDRESS, ,��� i ie' •`-� 1 PERMIT SR#; 0Oi8 <br />LICENSED CONTRACTORS DECLARATION LCD <br />I hereby offi,Tn that I am IICernaed raider 11e provisions of Chapter 9 (Corn mencing wnn Section 7000) of Division <br />3 of the BUsiness andProfessionsCode and my license is in full ford and effect' <br />Ci S r t Q Ex r tion Data: '�� l <br />License #: pins - <br />Date: ��. Contrcrcctor: �. G� C Q ��' 1 1 3 <br />Signature: \%, Title: V I a�s , ` <br />qr <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I heresy affirm under penalty of perjury one of the following deciaracons: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-!nsure for workers' cornpensatlon, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is lssuod. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of itis Labor Code, <br />for the performance of the work for which tthis permit is issued, My workers' compensation Insut'enco <br />carrier and policy numbers are_ <br />Carrier' � 1 ..�JC-1 0 0 a-1 policy Number: 0� <br />1 cartify that in the performance of the work for which this permit is Issued, I shall not arnploy any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that i' 1 <br />should become subject to the workers' Compensation provlsior,$ Of Section 3700 of the Labor Cycle, I shall <br />fcrth�^with comply with those provisions. <br />Date: `t 819n+rfurQ: <br />Printed Name: Of -" SK <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($700,000.), IN ADDMON TO THE 00$T OF COMPENSATION, INTEREST, ATTOR14fiY'8 FEES, AND DAMAGES A$ <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODF, <br />�a 0 ► • l a Ir (C•57Ilconsed authorised repreaeritative), ttwVby <br />authorize l( � c D d(-) I C S <br />to sign this San Joaquin County Well Patrttit Application on my behalf. I understand this aittttorizatlen is valid fOr <br />one (1) year and it limited to the work plan dated an tzie front page of thla application. <br />?-loan r eel <br />