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iff n AviiaverflL3 21 19166: 11 <br />kws t kb-ocupta-t-e <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement Co 311120 <br />JOB ADDRESS: 15 ,F-).‘ PERMIT <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter (commencing with Section 7000) of Division <br />3 of the Business and Professions Cede arid my license is In full force and effect. <br />I - 31 -0(p <br />License #: <br />Date! <br />Signature: <br />Printed name: <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 />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 />camel and policy numbers are: <br />Carrier: c1C,,\Kc.1. \CT\C- Policy Number: C''.1-)t.,W31-Q53 <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 />Data: 5 - <br />Printed Name: <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 QTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby authorize (print Vib <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 plan dated on the front page of this application. <br />3-19-03 / MI <br />Expiration Date: <br />CASCADE DRILL INC PAGE 02