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0 • <br /> San Joaquin County Environmental Health Department <br /> Fof <br /> ELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ��75 Si P t�s Lis 2 Tt" — PERMIT SR# <br /> ICENSED CONTRACTORS DECLARATION (LCD) <br /> affirmhat I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> California Business and Professions Code andmy license is in full force and effect. <br /> 10 Exp Date: 9/30/13 <br /> Date: 10/25/2012 Contractor: Cascade Drilling, L.P. <br /> �_) -- Title: Sr. Operations Manager <br /> Signature: � v <br /> Print Name: Paul Snelgrove <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> maintainI have and will <br /> p otvided for by Secon3700 oflthe tLabor cCode,toself-insure <br /> for the performance ofltp <br /> he work forlwhicch this <br /> permit is issued. <br /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: <br /> Alaska National Insurance Co. Policy Number: 12JSW30531 <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, 1 shall forthwith comply with those provisions. <br /> Exp. Date: <br /> 10/02/13 Signature: <br /> Print Name: Paul Snelgrove <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1��GS-- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) - to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EHI)29-1 07126110 <br />