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08/94/20091 14A14S 4IATAP.638561fax: 209937872n CASCADADRIL11IR1105 9:29 P. 04 PAGE 02/02 <br />Sate . udquiii ziiui, UiI4I 1Ne11 Peyoiii,App`l"I'luil Supplemeoz <br />I �.% <br />�IUis /�13Uk 6:�.� l --t ' � • I r ) r �r . i tRIVll 1 6R#: <br />r7 <br />LIGENSED CONTRACTORS DEOLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the $usiners and Professions Code and my lictmns is in full force and effect. <br />Llcense #; Expiration Date.— - (V _ w <br />Date: Co tractor:, <br />Signature: Title: d -e->ro : A n S eel <br />Printed name: �. a <br />..CRKERS' =41PENSATION QACI ORATION' <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and Wli maintain a certificnta of consent to self -insure for workers' compensation, as provided for <br />by Section 3700 of the Gabor Coda, for the performance of the work for which this permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Svetion 3700 of the Labor Code, <br />for the performancs of the work for which this permit is Issued- My Workers' compensation Insurance <br />currier anfd�pelicy numbers are: r� l <br />Carrier. _r.►.tv Policy Number: 05 N, t. ��d..:7� 1 <br />I GPr+ifif 4h�i in fFic norFnrrnvn.wc n4 �1io .nrlr i.�,,. f4 t ,.. s 1 ( 1 <br />. h: r ,� > pc—,,,t is �s,�u�.r,, i shul� 7ct employ any pErsor, IT, <br />any Mat <br />1nLar en r.. F .n.ra 0i:�psiiioaiivi 12'vVF Of Coliforn"zi,end mqr@j� that If i <br />should become sub)ectto the workers' compensation provisio of aectj 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. /� /, <br />i=xpiration Date:, i • y Cy slgno.Wre, <br />PrlgtF rd Name. <br />WARNING. FAILURE TO SECURE WORKF-RS' COMPrmNSA710N COvt-RAGE IS UNLAWFUL, AND 5HALl. SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AMU CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARr, <br />0100,000.), IN ADDITION To TtfE COST of COMPENSATION, INTEREST, ATTOPNEY's PEES, AND DAMAGES AS <br />PROVIDED FOR !N SFr.TInN .37P6 OF THF I.AROR CODE, <br />AUTHOR Tl FOR OTHER THAN 0-57 SIGNING PERMIT APPLICATION <br />Ir. __ I(9Ignature dfC-67 licennAti'authorized representative), <br />hereby authorize (print name) G 4"1 C ,- y_ r,\(,) <br />V <br />to sign this San Joaouin County Well Fermlt Application on my behalf. I understand this authorization is valid for <br />pile (1) yearand is lirmtea iu we work pilin datad on the front page of this application, <br />j 8_25-02 / M1 <br />BHD 29-0z-Wl <br />6a2104 <br />