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04/06/2005 21:14 9166385611 CASCADEDRILLING PAGE 02/02 <br /> '04/07/2505 89:38 915851F -10 <br /> 4#. catlon Supplement <br /> CatyEnVlronmcr'R1 Hearth Setnrloesoft IV well Perni0,111 ppu <br /> San Joaquin n <br /> DS PRMIT <br /> [JOB A � RBS : <br /> LICENSEE) CONTRACTORS DF-CLARATION (L"CD) <br /> I hereby affirm that 1 am lioonsed under the provision$of Chapter 9(commencing with Section-1000)of Division <br /> 3 of the Business and Professions Code and my license N in full force and eff t. <br /> Expiration Date. <br /> Llcense 4: , <br /> � 7 D S'� ntraG <br /> Hate: 1/ <br /> Tule" <br /> Slgnatura: <br /> �l - - ----�--- <br /> IPrintecl name- �d� <br /> WOFtKr=RS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> i <br /> -insur6 for Workers' <br /> n,as provided <br /> Section 3700of the Labor Code, tk <br /> for the perforManceof the work for which this permitfor by <br /> Is ssued. <br /> t <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Godo, <br /> for the performance of the work for which this permit Is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Canner" �iPolicy Number:, �7 /•SOf <br /> 1 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 subjact to the workers'compensation laws of California,and agree that If I <br /> should baoome subject to the workers'compensation proVisions of Seollon 3700 of tha Labor Code,I shall <br /> forthwith ate ply with those provisions. ^ <br /> Date: y 7 DS Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SEGURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND gOLLAAS <br /> ("oO,nao.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FERS,AND OAMAOES As <br /> PROVIDED FOR IN SECTION 37M O THE BOR CODE, <br /> 1, (scignature of0-57 Ilmnsed authufted reprasentative)" <br /> "rebpauthadze(print name_ <br /> to sign this San Joaquin county well Permit Application on my behalf. 1 understand thin authorization Is valid for <br /> one('i)year And in i1mited to the work,plan dslted an the front page of thft appllzt tfon. <br /> ti�9711A00 l f,Al <br />