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ivrzod 9166385611 CASCADEDPILLING PAGE 04/04 <br />9169E10430 SECOR rwt= C.P4IUM <br />0'5,1C/ 21305 Y4: OS <br />San Joaquin County Environmental Health Department Unit IV Well Permit Applicatioi Supplement oc_ <br />JOB ADI5RESS;Jtfar 00 1(?-00L___ , PERMIT SR: D z 3o) <br />ja (Al Ivinte-1KC0i'W€A4,1 <br />LICENSED CONTRACTORS DECLARATION (LC))) <br />1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing wIth Section 7000) of Division <br />3 of the Business and professions Code and my license is in full force and eft ct <br />License 4: i , Expiration Date: <br />Date: ‘,..-- Cant <br /> <br />Signature: "lite: Ad- <br />Printed name: A,:(/—"W---- <br />WORKERS' COMPENSATION DECLARATION <br />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 />_Z I have end will maintain workers' compensation insurance, as required by Section 3700 of the Liabor Code, <br />for the performance of the work for which this permit is issued. My warners' compensation insurance <br />carrier and policy numbers are: <br />carrion Afel-fia <br /> <br />Policy Number: <br /> <br />1 certify that In the performance of the work for which this perrnit is issued, I shall not employ any person in <br />ony 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 of Section 3700 of the Labor Cede, I shall <br />forthwith comply with hose provisions. <br />Expiration Date: Ce, Signatunst: <br />Printed NOMO: <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 />($100,0014 IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SEdTION nos OF THE LABOR CODE, <br />A THORI10 OR THER THAN C-57 SIGNING PERMIT APPLICATION <br />(si na ofC-57 liconsod authorlaed representative), gma <br />to 9ign this San Joaquin County Well Permit Application my bnlielf. I understand this Authorization Is valid for <br />ono (1) yoar and is limited to thoviork plan dated on the front page Of this apptIcatIon. <br />13-29.0 / <br />horoby authorize (print narno) <br />EHD 29-024)(H <br />bt,./.11/4