Laserfiche WebLink
02/20/2007 13:39 9166385611 CASCADEDRILLING PAGE 02/0,,�U <br />reo. LV, LVUI i I: Ijh�yl h a V R r C e 0 Ue0tnyl ronmeiitaI IVo, 1669 F. 2 <br />V!�° bn�f� Cas <br />San Joaquin County Environmental pepartmbnt Unit N Well Permit Appl�� iofl� Pplement <br />JOB ADDRESS./;2 O,3 _ PERMIT SR#'-Oo SSob 551 <br />Z ISO --CO 5ro6rQ� <br />LICENSED CONTRACTORS DECLARATION (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 Business annd�Professions Code and my license is in full force and effect, <br />License*:. I I -/ _ 571 0 _ Expimtion Date-- <br />Date; <br />ate:[late: 0 Contractor: n <br />Signature: Title: �)j' (() ry <br />Printcd name: a tltkC I r �r i1 \1 r jar& -L" c I I o <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under pensity of perjury one of the following ideclanatlons: (CHECK ONE) <br />I have and will maintain a certificate of consent to self -insure fbr warkarm' compensatlan, 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 insurante, as required by Section 3700 of the Labor code, <br />for the performance of the work for whirrh this permit is Issued, My workers' compensation insurance <br />carrier and policy numbers are: i r1 rP <br />Carrier: >A-Ij(0 �� fti 6(+,( l VT Ct Pafidy Number, n( e os 2osE <br />I certify that in the performance of the work for which this permit is issued, 1911911 not employ any person in <br />any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I <br />should become subject to the workers' cornpemation provisions of Section 3700 of the Labor Code, 18N.211 <br />forthwith comply with thnao provisions. <br />Expiration date; " 0 1 7Signature: <br />Printed Name:Zvi i�l ` r T—d n „ Jit 1 <br />WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND $HALL $UBJEGT <br />AN EMPLOYER TO CRIMINAL, PENALTIES AND CIVIL FiNE$ UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION 70 THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LASOR CODE, <br />AUT RIZATiON FOR 07HR THAN C-67 SiGNING PERMIT APPLICATION <br />1, T J (signature ofC•87 licensed authorized representative), <br />horsby nothorize (print name <br />LEE <br />to sign thlo San Joaquin County Well Permit ApplirAtlon on my behalf, I understand thin authorization Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />ERD 29.02-001 <br />MIMA <br />