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07/08/2003 16:01 19166385611 CASCADE DRILLING INC PAGE 05 <br />III %V <br />icatron 8upplemeltt <br />San Joaq <br />uin County Environmssrtal Flsatth pepttrlment Unit N Well Permit Ap <br />JOB ADDRESS: 7 <br />� PERMIT SRO: <br />LICENSED CONTRACTORS DECLARATION LCD <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70M of Division <br />3 of the Business and Professions Code and my license is in full force and effect.^11 ,I <br />Exp <br />7 �) d iration Date: <br />License *:11 <br />Date: o ractor: <br />Title: <br />Signature: <br />printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of pedury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self -insure for workers' compensitttion, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers aro: <br />Polley Number: _ �� I `� 1 <br />Carrier. <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 becomto e subject workers' <br />�� the �ompensationcem� osnastion laws edion 37100 ofie, and agree the Labor Code t1 if I <br />shall <br />should become sum h t ose proviSlons. ( 7 <br />forthwith comply \ , <br />Date: -j _C� ` signature: <br />printed Name: <br />SHALL <br />WARNING FAILURETOCRRIMNAL PENALTIES AND CIVIL UP TOON VERAGE IS UNLAWFUL, ONEE HUNDRED THOUSANDDDOLLARS EJECT <br />AN EMPLOYER TO <br />(;1oo, DED,IN FORN ADDITO THE COST OF TION <br />3708 OF THE LABOR CODE!OfV, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />PROM <br />AUTHORIZATION FOR QIBEff THAN C-57 SIGNING PERMIT APPLICATION <br />6A <br />hereby authorize (print name) TZ �► 1 `.••�� <br />to sign this San Joaquin County Well Permit Application on <br />WC -57 lioanaed authorized ropre&&ntative), <br />behalf. l understand this authorization Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-o21 M <br />