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02/20/2007 13:39 9166385611 CASCADEDRILLING <br />reQ,,(u, LUUI II:IJ&Yl navancel �eotnvironmertal <br />co <br />ALV � aIVf 070:�e -, cos <br />No, /Oli9 <br />PAGE 02/D,�D <br />F. 2 <br />IN <br />• <br />San Joaquin County Environmental Health Departmbnt Unit IV Well Pormit Applicata t00 Supplement <br />JOB ADDRESS..', �'`� PERMIT SR#��o Sob 5� <br />2- /..So <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions cf 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. <br />License #; I I _ Expiration Date: <br />Date; ContractcrCi <br />Signature: Title: � (() ml_ <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />1 hernby affirm under penelty of perjury one of the following :declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self -insure for warki rm' compensation, as provided for <br />by Section 3740 of the Labor Code, for the performancb of the work for which this permit Is Issued. <br />I have and will maintain workers' compensat Qn 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)I ��numbers are.- <br />Carrier: <br />re:Carrier: C( -V( 0 k� a Poiidy Number; <br />I certify that in the performance of the work for wNch this permit is issued, I shall not employ any permdn 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' componsation provisions of Section 3700 of the Labor Code, I shalt <br />forthwith comply with thcae provisions. <br />Expiration date; _ 0_7 Signature; <br />Pdnted Name: `r J a ran�-? <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVCRAGE IS UNLAWFUL, AND SHALL SUnJCCT <br />AN EMPI.QYER TO CRIMINAL, PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($700,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR, IN SECTION 3706 OF THE LABOR CODE, <br />AUT RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I. J (signature ofC-67 licensed authorized representative), <br />horaby authorize (print name) _R Y 4 67 <br />- � c <br />to sign thlo San Joaquin County Woll Permit AppiibAtlon on my behalf. I understand thin authorization Is vallrf for <br />one (1) year and Is Ilmlted to the work pian dated on the front page of this application. <br />M 2902-001 <br />M)IAA <br />