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Signature: <br />Printed name: <br />\.(1Z4; PcfR A-K). <br />10/25/2228 12:33 19166385611 CASCADE DRILLING INC <br />. .. , <br /> _____ . n -Jotquin:_Courity Envirorirrentai Health Services; Uri.it IV Well Permit Applica.tiOnSupplement _ _. ' <br />JOB-ADDRES$_37 £ / fr.7 -1e.r.- _ <br /> <br />SY-o. c_kTic <br />PERM rT sfk#: -ccqz:(9.( f <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provision of Chapter 9 (commencing w th Section 7000) of Division 3 of the Rusin ess end Professions Code and my license is in full force and effect. <br />License #. a5r/ ritri5m <br />Datg: DO <br />antrt'..kctcr: <br />WORKERS COMPENSATION DECLARATION <br />i hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of conswIt to self-insure fcr workers' compensation, as provided for by <br />Section 3700 of he Loeor Code, for the perform an of the work for which this perrnit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of :he Labor Code. <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: AVSka.._140,g0 , tns Policy Number: ODEWS3 0531 <br />_ I certify that in the perforrnance of the work for which this perm,t is issued, I shall not employ any person in <br />any manner so as Co became subject to the workers' compensa laws of California. and agree that if I should become subject to tie workers' compensation o isle Section 3700 of the Labor Code, I shall <br />forthwith comply wl:ri those provisions <br />• Date" to -Ia. -20. Signature: <br />Printed Name; <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,003.), 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 />CAP.& tvipd\I <br />Expiration Date: — 31 -7 0 <br />Cascaifir.rdlt-n I <br />Till.; 0 Mt_4T1UKAALL:R EO.,..__ <br />1, V era_ Ck <br />6 cr-z_o/D authorize <br />(C-57 licensed authorized representative), hereby <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this euthoriratIon Is valld for <br />one (1) year and is limited to the work plan dated on the front page of this apptication. <br />L5-1-200 /Ml <br />PAGE 0? <br />0