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06/29/2006 12:50 9166385611 CASCADEDRILLING PAGE 03/03 <br />JUN-��-� � � HU U (I bb 8Mlrl{1=Y6fUNlr hHl< NU. b4Jlyb5 r, 2- <br />JAVI <br />o� _ �9c <br />San Joaquin County�Environmental Health Deparrttment Unit IV Well Permit Application Supplement <br />.lt3i3 ADDRESS: 4�� (%►�.u/&O PERMIT SR#: Q <br />LICENSED CONTRACTORS DECLARATION LCB <br />I horeby .affirm that I am licensed under tha provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 df the Business and ProfesRions Code and my license is in full force and effect, <br />Expiration Date: 1 3 t 0 <br />Sittnature: <br />Pi6ntod name; <br />Title. u S <br />WORKERS' COMPENSATiON DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Cade, for Vie performanco of the work for which this permit is issvcd. <br />I have and will maintain workers' compensation Insurance, as regUlmd by Section 3700 of the Labor Code, <br />for the porformanta of the work for which this permit is issued. My workers' compensation insurance <br />terrier and policy numbers aro: <br />'Carrier: 1 a c - ��>c -,-A Policy Number: 3o.S <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 as to become sueicot tb the workers" compensation laws of California, and agree that if I <br />should b acorne subject to the workers' compensation provisions of Section 3700 of the labor Code, i shall <br />forthwilth comply with those provisions, <br />Expiration Dater�� Signaturo; <br />Printed Name: <br />WARNING: FAILURE: TO SECUKF� WORKERS' COMPENSAT(QN COVERAGE 13 UNLAWFUL, AND SHALL SUBJECT <br />AN ZMPLOYFR TO CRIMINAL PENALTIES AND CIVIL, FINES UP TO ONE HUNDRED] THOUSAND DOLLARS <br />IN ADDITION To THE COST OF COMPBNSATiON, INTEREST, ATTORNEYS FEES, AND DAMAGES As <br />MOVIDED FOR IN SFCTfON a706 OF THE LABOR aODD. <br />AUTHORIZATION F OiNER TMAN C-57 SIGNING PERMIT APPLICATION <br />c� <br />'-' -�� (slgnaturo etC.57 GCertsed uothorzed rap�gcatative), <br />Itiv Y AvOwrize (print name) ro n y M �1 <br />a sign this San Joaquin County Well Permit Application on my behalf. I understand this authorizaition Is valid for <br />ne if) year and is limited to the work plan dat6d on Ute front pailc of this application. <br />-2s .!2 TI _ _ I <br />141P 27Q2401 <br />412ZIN <br />