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San Joaquin Ca:cntyy Environmgnv:al Health S rvice�s, unit !V t'vell P rmlt Application Supplement <br />�oSeeo ! (l qA <br />JOB AIDDREMS; SC,/"(. <br />PERM! SR#: 00 320 fo r <br />LICENSED GONT%.TORS ®ECLARA CON (LCD) <br />her-:ty aftirir, tfiiFt i am iiceno�3d Tinier the prr-,0&;oris ?f C,"ta;7ter Q (c-.mme✓ ing with Section 7MO) of J"!i <br />Sty,^ <br />`.2 Jf the BLSM.e&S 6110 PrQfeS$iorlS C.nde end !r, Ir!s�rr8e is in full Tome and ef�ect. <br />C57-717510 <br />Date. 6/26/02 Cascade Drilling, ';inc. <br />j Sign atrrr� _ Title- Operations Manager <br />i <br />Printed Warne; Vera C apman <br />WORKER MiAPENSATION DECLARAtION <br />l ; h8, ebv a` -7 u'? J?r pei aity vt peritur; cr e cf C,,;•* ftllovii.,g declarations: (CHECK ALL THAT APPLY) <br />I � <br />rid, W 'l n1Gt.ili ti w2r?f?iC$1C9 of -On2daIt tocjR_irr , o <br />sue for �wor''K rs', corm. p0 nsation, as provided for by <br />Labar Code, far'Unrz p;;fo:-mance of the. work for whi;;�i this permit is issued. <br />X i neva and w:] ma -Int aii-i Workers' c:orrpen ,atio- ir,aurari� �. es required btv Section 37CO of he Labor Code, <br />t1� G : F •;)� nc�ilCe :�� ..:rk. `+JC 5h`}1iG? this permit iS .dsued. My wor{ -(is' corn Fensation insurance <br />carrier Pao :a'iuy nu Leers Ere: <br />i <br />Carrier Alaska National ?o;'cy Number: 02EWS30531 <br />certify that it the per -o"- ance of t!^e jvo,i(for which this permit is issued, I shall not employ any person it <br />1 -MI. manner So as t-:� iY otZl$ Subject to the wo�r;.ers' ^�"T-Ji'rlSatiC 1 laws pf California, and agree fh'at if i <br />should subject to the worker F' co. rnpensacior. prov'"'Os] of Sec6n 3700 of the Labor Code, I Sail <br />forth:wim-a0m,-!v with ;.hose picv'.sions_ <br />j Date: _ 6/26/02 <br />Pripfed Nars;e: Vera ChaAman <br />WARNING: FAILURE TO SECURE rl(CjrRKERS' C4MFEN �A-r10Ni COVERAGE IS PNLAWFUL, AND SHALL SUBJECT <br />AN EMP: -OYER TO CRIMINAL PENAL EES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.),.IN ADDITION TO THE COST 4F COMPENSATION, IN z"EREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PRCViDED FOR IN SE-rY,rD1�,87f1S OF TFIE LABOR CODE. <br />(signature ofC-57 licensed authorized representative;, <br />hereby au• razz rinr ,arsrE3-°c-,S m.� - - /Q ji�t-/ <br />to sign this van Jo in County Wall Permit App!:"tiur" an my behalf, t understand this authorization is valid for <br />��. ,. •1.:._. _. <br />one (1) year and is E'r )) ted .a the work plan dated or thin front page of tf <br />L5-1 7.2000 i Wo <br />