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3 10 Ed 1i1:58 19166385611 <br />1;2:55 FAX I 916 B51 0431: <br />CASCADE DRILLING INC <br />SECOK- SACKVWN <br />EI84 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: tow 442.051 ert • PERMIT SR*: ev-314, OE <br />(We <br />' <br />, <br />Muj <br />rDp <br />vi) -13 miA)-14) <br />LICENSED CONTRACTORS DECLARATION (Lcp) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section /000) of Division <br />3 of the Business and Professions Code and my license is in full lorce and effect. <br />License t CS i7.7 / 7-S-7 0 Expiration Date: -3/--- 0 ti <br />Dote: /0 -1 6 0 Contractor: s c a <br />Signature: Title: <br />Printed name: Ve./rQ. CI a ( 4/-v1 <br />WORKERS' COMPENSATION OECLARATIN <br />hereby affirm under penalty of perjury one of the i0110Wifig declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance ot the work for which this permit 13 issued, <br />X I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Coda, <br />for the performance of me work for which this permit is issued. My workers' compensation Insurance <br />carrier arid policy numbers are: <br />Carrier:fr/a1<0 Ais*7 _14 d 4 q /Policy Number:. 00_d EtA)s 303 ] <br />I certify that in the performance of the work for which this permit is issUOdi 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 Ill <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br /> Signature' <br />Printed Name: V-c <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 />(1100,001). IN ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEY'S FtES, AND DAMAMES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />, Vera CA ark__ _ (signaturo otC-S7 Ronson outhorttod roprosiontatIve), <br />herebyoulhortze (print nonie), ITO atwal i filet <br />to sign this San Joaquin County Well Perrnh Application on my wham I understood this authorization Is valid for <br />one (1) ear And Is limited to the WOrk plin doted on the front pogo of this appilostlion. <br />S-174000 131