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06/29/2006 12:50 9166385F71 CASCADEDRILLING PAGE 03/03 <br /> JUN-28-LIUUU 'IHU U(Ibb HM ' 'SIVNh hHri NU, 1:14J) V. ue <br /> /� � <br /> F9a <br /> � <br /> San Joaquin CountyEn1vironmenta/l/Health l7epadAmenx Unit IV Well Permit Application Supplement <br /> Jl]B ADDRESS: 4 /� 1 �X�yxc�/ec�o( PERMIT $R#.-b-!Qy <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under Ina provisions of Chapter 9(commencing with section 7000)of Division <br /> 3 df the Business and Professions Code and my license is in full force and effect. <br /> Lif."nso M -�r�jy o _ Expiration Date: l i t 0 <br /> Uai.e: 6 _a `U Contra Or. < - <br /> Signeture: 7itle: l�t„"`�''"--'� <br /> Printed name; <br /> WORKERS'COMPENSATION DECLARATION <br /> I h,hreby affirm under penalty 0 perjury one of the following doclaraiions: (CHECK ONE) <br /> _ <br /> - I have and will maintain a certificate of consent to self-Insure for worker; compensation.as provided for <br /> by Section 3700 of me Labor Code,for 6)e performanco of the work for which"'ispermit is issuod. <br /> I have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for Gio porformance Of the work for which this permit is issued. My workers'compensation insurance <br /> Carrier and policy numbers aro: <br /> Policy Number: c: �3 <br /> 1 certify that in the performance of the work for which INS permit is issued, (shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Califomla, and agree that if I <br /> should became subject to the workers'compensation provisions of Section 3700 Of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Ex �_���,_��' <br /> f�irat(onDalo5 J 7 Signature; <br /> Printed Name: fir! ���/(„-f"I clry-e'�� <br /> WAQNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br /> (bifk,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PRQVIOED FOR M SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION F OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> f --'—` —r-- (signaturo WC-57(tensed authorized representative), <br /> hornby audror¢c(printame) I o n.y GL M V�'- <br /> J <br /> to sign this San Joaquin county Weil Permit AppfigtioR on my behalf. f understand this authorization is valid for <br /> one 11)year sad is limited to the work plan dal'ed on ORe front page of this apOcotion. <br /> tFID z^,qz-ret <br /> 6avO t <br />