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®3 22/ 003" `► 7It 52 <br />San J <br />19166385611 <br />9169610430 <br />V 0 Jaz V �0 <br />UuWtv Environmental Health S <br />CASCADE DRILLING INC <br />SECOR <br />JOB ADDRESS: lr�G� �/taI/.D hyo <br />ge <br />PAGE 612 <br />PAGE 02/02 <br />nit IV Well Permit APPIICAtion suppiement <br />PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (jam) <br />1 r oreCy affirm that I am licensed under th4 provisions of Chapter 9 (Commencing with Section 7000) of division <br />3 of the RU5ines$ and Profs;sigrt8 Code and my license is in full force and offset. <br />License #, Q•5 -? -7 ! 5 ( Q Expiration Date:_Isz_� <br />Date' _ U Cantractor: <br />Signature, <br />Title: <br />Printer! name: �. IV <br />— <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under pena.ty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compenaatim, as provided for by <br />Secton 3700 of the Labor Code, for the perfvrmanCe of the work for which th s permit Is issued. <br />I have and wilt maintain wo kers' compensation insurance, as requirea bySectlon 3700 of the Labor Code, <br />for the parfo(mance of the work for wh ch thls permit is issued. My workers' rompenaetior Insurarte <br />carrier and policy numbers rt' <br />1 Carrier: Policy Nurnl�rr:F'� a7 p`� f <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 ab to becorna Subject to the workers' compensatlon laws of Calllfornls, and agree that if I <br />I should become subject to the workers' compensatlon provisions of Section 3700 of the Labor Coda, I shell <br />forthwith comply Witte those provisions. <br />II Date:' cls �� 31�nature: _ <br />Printed Name: -- <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYIER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S1QO,Ooo.), IN ADDITION TO THE Cii OF COMDI!NSATION, INTERE8r, ATTORNEY'S Fr.ES, AND DAMAGES AS <br />PROVIDED FOR IN SEC ION 3706 Or THE LABOR CODE. <br />I (;Ignaturn ofe-57 licensed sutho ed repressntatrve), <br />, <br />harrby author m (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf, I understand this authoftatlon la valid for <br />one (1) year and Is limited to the work plan dated on the front page of 11116 NP131110 lvn, <br />5.17.20t)d i AAI - <br />