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PAGE 02/02 <br />H4.)O1 0:eith,2 <br />CASCADEDRILLING <br />bEUUH <br />11/22/2005 08:52 9166385611 <br />11/21/2005 •111: JID `J-Liak:a01.1J430 <br />tmAl <br />San Joaquin County EnvirOninentAl Health Department Unit IV Well Pormlt Application Supplement <br />JOB ADDRESS: .16 70 C PERMIT SRO: 0045 / ( 2— <br />/•4/1/1-rvii f (4. <br />LICENSED 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 and my license is in full force and effect. <br />Line:? 7175'? <br />Data: c213, ontractor: c 9 .01 y <br />SIgnatUre: Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of tho Wowing declarations (CHECK ONE) <br />I have and will maintain a certificato of consent to self-insure for Workers' compensation, as provided for by Section 5700 of the Labor Code, for the performance of the work for which this permit is issued. X I have <br />and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the wprk for which this permit Is Issued. My workers' compensation Insurance carrier and policy numbers are: <br />A Carrier: 4-1 Polley Number; 05 <br />certify that in the performance of the work for which thls 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, rind aproe that if <br />forthwith comply with those provisions <br />should become <br />subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />Expiration Date: 0 C Signature; <br />Expiration Date: / - 3 ( <br />Printed Name: _ 6 0 1,,.1•- - k __ a _ z ,—,± al sw__ 0 c„-----4_,- <br />.....___ <br />WARNING; FAILURE TO SECURE WORKERS' CoMPENSATION cavVrtAoa IS UNLAWFUL, AND SHALL SUBJECT AN erwini,gyER TO CRIMINAL PENALTIES AND ciVIL FINES UP TO ONE HUNDRED THOUSAND naLLARs <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTFIREST, ATTORNEY'S FEES, AND DAMACES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION OR AMER THAN C-57 SIGNING PERMIT APPLICATION <br /> <br />(signature ofC-57 licensed authorizna rnprenOntative), <br />4 ttereby authorize (print name) <br /> <br />to sign this Son JoaquIn County Well <br />Permit Application on my behalf. I understand *lit authorization is valid for <br />ant (1) year and is limited to the work plan dated on the front page <br />of till.% application. 29-02 /MI <br />ETTID 29-D2-001 <br />6/22./04