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02/20/2007 13:39 9166385611 <br />JAMM ! I: I�HIV! Nava�ceQ <br />CASCADEDRILLING <br />0e0LnYI roflmentdl '06 <br />6-Itl c� <br />No, 149 <br />PAGE 02/0ru <br />r1. 2 <br />IN• <br />San Joaquin County Environmental Health Departmbnt Unit N Well Permit AppIOO rofC Rplernent <br />JOB ADDRESS. 2103 _ PERMIT SR# �Oo 555�b 55�i <br />Z I,SO --CC So6&0 <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 and Professions Code and my license Is In full force and effect, r <br />License #; � 1-7 S7i 0 Expiration Date- <br />119 <br />ate- <br />1T _! <br />Date: 119 ! 0 Contractor: eq, tJ n 1 } " -- n C.,_ <br />Signature.' Title: ''(0 rim <br />M v 1 oil N f jar <br />(� 1 <br />Printed name; <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penslty of perjury one of the following .declarations,- (CHECK ONE) <br />I have and will maintain a certificate of consent to self-i'nsure for warkers' compensation, as provided for <br />by Sectlon 3700 of the Labor Code, for the performanrk of the work for which this permit Is issued. <br />I have and will maintain workers' compensation insurance, as required by 5eation 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 polloy numbers are: ll rr11 �P <br />Carrier: NO �ya lV C(—V1 <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 io `ovisions of Section 3700 of the Labor Code, I sh21f <br />forthwith comply with Ehoseprovisions. <br />Expiration Date; 0s17Signature; <br />r <br />Printed Names <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMiNAI, PENALTIES AND CIVIL FiNES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($1QO,U00.j, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, ANC) DAMAGES AS <br />PROVIDED FOR 1N SECTION $706 OF THE LABQR CODE" <br />AUT RIZATION FOR OTHER THAN C-67 SiGNING PERMIT APPLICATION <br />1, (signature ofC•57 licensed authorized representative), <br />haraby authorize (print name) <br />to sign this Sart Joaquin County W,&II Permit Applleatlon on my behalf, I understand this authorization Is valid for <br />one (1) year and Is limited to the work pian dated on the front page or this application. <br />8-2942 J Ml <br />EM 29.02-001 <br />4 M17 /M <br />