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hereby authortae (print me) 67 <br /> (signature ofC-57 licensee, authorise. repieeareative). <br />red 0 <br /> <br />A' 20 , lb: 48 181 SE <br /> <br />-06(29i 12: 00 b027280738 . . <br />CASCADE DRILLING INC PAGE u2 <br />;LAES PAGE 01 <br />111)112 N. <br />1 Iclebe • "/L -)02-44- . <br />oet- San Joaquin County EnvIr mental Health Department Unit IV Wall Penni! Application Supp4orniant <br />JOB ADDRESS: e a zd ., PERMIT SRI: 0/Y/ a, <br /> <br />pi 2 2'0 -- <br />LICENSED CONI-fw,iirits DECLARATION USW <br />I hereby ferrn that I am licensed under the provisions of Chapter 9 (commencing with Sectiom 7000) Of Division <br />3 of the Business and Protonic -is Code and my license is in fun forte and effect <br />License 0: 0.5_1 7/ -75-1 Expiration Date: / / C ti <br />Signature: <br />Printed nem*:C7) <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury ono of the foilw4ing declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certecate of consent lc solf-lnsure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, forth. offprinance of the work for which this permit Is issued. <br />I have and maintain w•I'kUrt rin4rtitic4. as iec.jUineO :3ection MO of the Labor Code. <br />ior POnorrnon or tno wpm 1r which this permit ts isbuad. My WOTI m tOTV compensation Irieurenoe <br />carrier and policy numbers are: <br />Carrier: askct zma pow ,LE ws-,36LK--3 ( <br />- I certify that In the performance or tne work for which thla permit is lulled, I Shalt not employ any persdn in <br />any manner so es to t.)ecorne eubitict to the workers' compensation laws of Califomie, and wee that If I <br />should become subject to the workers' oompensetion provisions ofectin 3700 of the Labor Cede, I Olaf <br />forthwith comply with those provielonS. <br />Date: 2-r- SIG Neu : <br />Printed Name: t/ 1—cx- C Cte/ YI,P\ f\- <br />WARNIN(1: FAILURS TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL ISUSJECT <br />AN vaPt.one TO CRIMINAL PENALTIES AND CIVIL PiNES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(51003,0X.), IN Atmrrioie TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED POR i C71 3704 OF THe LAsoia cope. <br />to sign this San Joaquln County Wait Permit Application on my bahalt. I undsrptand this authorization *vglid far <br />ono (1) year and is limited to the wort plan dated on the front stage of this application. <br />1.21.02 /MI <br />Contracto C cc.SCc7 cl. D (/" r, <br />er ns /lct yrt-