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06/29/2006 12: <br />J UfV-�:1-'CUUp <br />AV ITAO <br />50 9166385611 <br />Ihu UW)C) HI -1 IUK11rZ1UNC <br />CASCADEDRILLING <br />I nn nv. u4_1 i ejlj;o <br />k 0-Aj I le P -w i U0/(-/' <br />Ban Jadquin County Environrnental Haalth Departim Unit N <br />*aA' D Co C;P,c� <br />PAGE 02/03 <br />1. - <br />Permit Applieati n Supplement <br />j%jU AdDf�E55: 3 PERMIT SR#: i�T6110 <br />LICENSED CONTRACTORS DECLARATION (LCD <br />I I'lereby affirm that I am licensed under the pravisionti of Chapter 9 (commencing Wfth Section 7000) of Di0sior <br />3 of the Business and Professions Code and my license is in full force and effect. <br />L i,;,onse #; ,jr\'*� S\ iz t� ` Expiration nate: \ t 08 <br />D.Ae: (= ..WG 15;1 v (:nnrnnln1 ��. <br />Slanature: <br />Printed name: <br />Tift s nrj <br />f 7 - - <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under panalty of perjury one or the following dsdarations: (CHECK ONE) <br />I hays and will mainteln a certificate of consent to self -insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work forwhich this permit is Issued. <br />I haVe and will maintain workers' comPensatlon insurance, as required by Section 3700 of fhe Lahr Code, <br />for the porfonrtance of th® work for which this permit Is issued, My Workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: Lc1S7+� t.) A� Policy Nurnber. _b C \ <br />��o��_, <br />I certify that In the performance of the work for which this permit is Issued, I shall not employ an <br />any manner so as to become subject to the workers' compensation laws of catifornia, and gree hat it I in <br />should become subject to the workers' compensation provisions of Saetion 370 of the Labor Code, I shall <br />forthwith Comply with those provisions. <br />Expiration pate: 5---�� Signature: <br />Printed Name, UU <br />WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBjecr <br />AN kMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100.040.), IN ADbITION To THE COST OF COMPENsAlION, INTEREST, ATTORNEY'S FEES, AND DAMAGpS AS <br />Pftr)V1OL0 FOR IN SECTION 3706 OF THE LAMOR CODE. <br />=AUTHORION F0 ER THAN C-57 SIGNING PERMIT APPLICATION <br />(signAture 0047 liven&ed authorized representative), <br />hert,tty authorw� (print name),— <br />to Sign this San Joaquin County Wc11 Permit Application an my behalf. I understand this Outhatization Is valid for ' <br />ono (1) year and is limited to tho wo k plan dated on Rho reont page of this appgc3tian. <br />8.2a •02 f M1 <br />MUI 29 (11.(101 <br />b22/0.4 <br />