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R <br />x01/205`09:35 91663°5611 CASCADEDRILLING PAGE 02/02 <br />/2 <br />�zd, I �, Euj,- 2, 4) <br />San Joaquin County Environmentat Health Department Unit IV Well Permit ApplicatinSupplement <br />,ao AC)C��tESS: 1O 1%0, PERMIT SR#: 001 <br />313 <br />LICENSED CONTRACTORS DECLARATIONL( Gill <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of T,ie Business and Professions Code and my license is ir^ full force and effect. <br />License #: ��� �� Expiration Date: Ile <br />Gate: _ l�S'/� Cgntractg <br />Signature: <br />Printed name: <br />Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />_ I have and wil! maintain a certificate of consent to selfansure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the perfc: mance of the work for which this permit is issued. <br />`lhave 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 />carri,�r and policy number-, are: <br />Carrier: ` •�i�� r� Policy Number, Q "� 1513 _5y <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 subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the tabor Code. I shall <br />forthwith c mply with those provisions, <br />Date: / zS O� Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, A':D SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL. FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES ;-,S <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZAT N P a ER -THAN C-57 SIGN'NG PERMIT APPLICATION <br />t, (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name)'- <br />to <br />ame)_to sign this.:San Joaquin•Co4inty,WeN Permit Application on my behalf. I 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 />8-29-02/ MI <br />