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Date: <br />Signature: <br />Printed name: <br />I A , 04/23/2004 13:21 19166 -311 <br />0 <br />A,LuS LOD er. tAiiptd-e-e <br />San JOaquin <br />County Environmental Health Department Unit IV Well Permit Application Supplement Co 3 1-(7-0 <br />JOB ADDRESS: 6 <br /> PERMIT SRit:00,31- /-.127 <br />LICENSED CONTRACTORS DECLARATION (Lg.?) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing ‘vtth Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: (7 Cl LO Expiration Date: / 31 —0 Cr; <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one Of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-Insure for workers compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have and will maintain workers' compensation 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 numbers are: <br />Policy Number: _ C\---LtrW3,?'1(35 <br />I certify that in the performance of the work for which this permit is issued, 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 if I <br />should become subject to the workers' compensation provisions Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions <br />Expiration <br />Date: 5 - 1-45 <br /> Signature: <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 />($100.000.), 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 />AUTHO TIO FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />I.tk (signature of C-157 licensed authorized representative), <br />. , <br />hereby authorize (print nneL rYii‘ 1_4- ViA.A_O.c <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plen.datted on the front page of this application. <br />3-19-03 / MI <br />Carrier: <br />Printed Name: \LL`e V9)YThri)f--1 <br />CASCADE DRILL INC PAGE 02