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4 <br /> AflA, <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB=ADR�&S E. PERMIT SRMALA2-5 <br /> LICENSED CONTRACTORS DECLARATION (!,CD) <br /> I 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 for and effect. <br /> License Expiration Date: 9/30/2011 <br /> bate; 7/1/2010 Contractor Cascade Drilling, L.P. <br /> SignatuTlOperations Manager <br /> re: ite: <br /> Paul Snelgrove <br /> Printed name: <br /> WOR KERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self4msure 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 /> carder and policy numbers are: <br /> Carrier: American Zurich Insurance Co. Policy Number: WC399959-01 <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 I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date; 10/2/2010 Signature: <br /> Printed Name: Paul Snelgrove <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATT ON COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> ANE LOYER TO CRIMINAL PENALTIES AND CIVIL FINES 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 OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name)All <br /> to sign this San Joaquin County Wail Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-2"2 1 MI <br /> EHD 21�-02-011 <br /> N,12104 <br />