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A UTHOR,..i: <br />?1\19V, E3; 3812019166APEX ENV IROTECH, INC. CASCADEDRILLING <br /> NO.156 P. 3:4E <br />Au/J.5'45A (pa, <br />/e-t9& g6-05---3c9o—APAI snn Joaquin County Environmental Health Department Unit IV Wert Perrnit Ap cation SuPP <br />JOB ADDRESS: <br />PRMIT c 4- <br />LIPENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and professions Code 1-1c1 my license is in full force ant effect. <br />License 4-, 15 I 7 5 ( 0 <br />; Date:-14.05 Contractor <br />Signature; <br />Printed name: <br />WORKERs" COMPENSATION DECLARAT1oN <br />I hereby effirm under penalty orf perjury Crie of the folicwing declarations: (CHECK <br />ONE) <br />1 ' hal:/c ant will maintain a cerffcate of consent i if-inure for workormi compensaiich, as provided for ' <br />by Sar;tidn 170C of The Labor Coda, for the performance Oft Work for Which this' permit is issued. <br />X I have and will maintain workers' compensation insuranee, as required by Section 3700 of the Labor Code, for the performance of frie work for which this permit IS Issued, My Workers' compensation insurance aarrier end policy numbers era: <br />Carrier: <br />ted Name: rel WARNING: rAILUP.z <br />TO SECURE WORKERS' COMpENsATIoN COVERAGE IS UNLAWFUL, AND SHALL SUEJEcT AN EMPLOYERIc CRIMINAL FE4ALT1ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(3100,4300.), IN ADDITIoN TO THE COST OF COMpENSAT1ON, INTEREST, ATTORNEY'S S. AND DAN/AGES AS pROVIDED FOR IN SECTiCN 37o6 OF THE LABOR CODE <br />nerehy authorize Ibrint nrnC..e. r\r). a r.4- Lc% <br />to Argo this Sr Joaquin County Virgil Permit Appilovion on my behalf. I untierstann thl;auth <br />-----orlzatIon IS VA lid for one (1) yen r and is limited to the work in dated on the front pAge of this application. <br />C-25-02 / MI <br />'-1•M 23-0)401 <br />6/22/:14 <br />ement <br />702- <br />Expiration Date; __I 3 0 (4.) <br />Polity Number: <br />I <br />certify that in the performance of the work for which this pemlit is Issued, I shall not employ eny person in <br />any mariner se es to beccrne stieject to the mincers' compensation laws of California, and agree That in <br />should become sLrbJect to the workers' compensation prtovitio of Sect' 3700 et the Labor Code, Ishall forthwith comply with those provisions. <br />Eviratlen - (0 SIgnahlre: <br />FOR Q frrigH. THAN C-57 SIGNING PERMIT APPLICATION <br />(aignature arC•67 fiennsed Ruthortzed rapresenianvel,