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s � R <br /> San Joaquin County Environmental Health Department Unit Iv Well Permit Application Supplement <br /> JOB ADDRESS: �� � � ��y` ;" PERMITSR#A%D_�Vo <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 70010 of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License : Expiration Date. 913012011 <br /> Date: 71112010 Contractor: Cascade Drilling, L.P. <br /> Signature: Title: Operations Manager <br /> Printed name: Paul Snelgrove <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby Arm 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 /> X I 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 /> crier and policy numbers are: <br /> Carrier: American Zurich Insurance Co. Policy Number: WC3999959-01 <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 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Lahr Code, I shall <br /> forthwith comply with those provisions. <br /> s <br /> 2010 <br /> Expiration Date: 10121/ Signature: <br /> Print Marne: Paul Snelgrove <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES 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 /> AUTHORIZATION FOR E THAN C-67 SINNING PERMIT APPLICATION <br /> } 1 <br /> (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name <br /> to sign this San Joaquin County Well pe it Application on my behalf. I undenuand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. <br /> 8-29-021 MI <br />