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09/18/2001 14:51 19166365611 CASCADE DRILLINGINC <br /> 10, 17'01 KON 14:19 FAX 1 91w--Y91 U4au JlClurs-Jn�nn�.�,av _ PAGE 03 <br /> 20'Silg <br /> Sar►Joaquin County Environmental Health 8ervicaa,Unit IV Well Pomdt Appileation Supplement <br /> JOB ADDRESS: VA PERMIT ORS: <br /> LICENSED CONTRACTORS DECLARATION (LCD)- <br /> ; <br /> I hereby affirm that I am licansed under the provisions of Chapter 9(commencing with Section 7000)of Dtvlsion <br /> 3 of the Business end prdfeasions Code and my license is in full force and ofeat_ <br /> � � /— 0Q <br /> License#: ? -7 j :.� l � Eacpiratian Date: <br /> Date:9ntractor: Ciltkn 01 <br /> Signature: Title: <br /> Printed name <br /> WORWERS' COMPENSATION DECLARATION <br /> I <br /> heresy affirm under penalty of perjury one of the following declarations, (CHECK ALL T 4AT APPLY) i <br /> I haw®ono will maintain a certificate of cor=nt to SBIf-Insure for workers'aompansatlon,as provided for by <br /> Section 3700 of the LNOW Code,for the performence of the work for which this permit is issued. <br /> XI ha"and w1M maintain workwir compensation Insurance. as required by Section 3700 of the Labor Code. <br /> for the perforrnanCe of tna wojW for Walt h this perrnft is Issued. My workers'compensation insurance <br /> carrier and policy numbers are; <br /> Canrlor. Po{ipy Nurnber: <br /> _I certify that fn the performance of the work for which tats pomM i6 imued, I shalt not emploY any Person in <br /> any manner so as to batama subject to on workers'compenaa0m taws of Cal0onnla,and agree mac it I <br /> 3hotllo bq=me subject to the workers'compensatio4pM0MvI nsof don 3700 of the Labor Code.I shall <br /> forthwith comply wrTh those provlsions. <br /> Date: r �! 0' Signature- <br /> Printed Name: VbfoL <br /> WARNING:FAILURlr TO SECURE WORKERS'COMPENSATION COVEIitAGE IS UNLAtrI/FUL,AND SHALL.SUSJt:CT <br /> AN EMPLOYER To CRIMINAL PCMALTE3 AND CML FINES UP TO ONE HUNDSIEDZHOl MND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,AT r0RNFrS FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECnOtN 3706 OF THE LABOR CODE. <br /> L^Vt9_r0,_ �.� a fL (signature olC47 licar o audwrised rep"Wntative), <br /> hereby authartaa(print narne) r"t vr� t 0.- <br /> to sign oug*Ian Jo",,ln"untyWell Pern"APPltcatfaa on my beAalf. 1 unesrstaW hIs aulhort"110n isv*W for <br /> one(1)year and Is llrnitad to the work plan daod'on the frms page af thls appllcatlan. <br /> S-17-20M I MI <br /> via 39t�d �v�J �1dld t:srbE89��0i: EE=et e89ZIVO/ZT <br />