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05/02/2002 12:33 19166385611 CASCADE DRILLING INC PAGE 92 <br /> . - <br /> !;5--U2--02 TIM 08:53 F&)t 1 slK sial ll43u ��Vulr-�llllCA�RLIVIV <br /> 45iYu• <br /> San Joaquin County Environmental Health Services.Unit IV Well Permit Appllendon Suipphnner-A <br /> JOB ADDRE=SS: p, a c4PERMIT SR#i: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I art ilcensed undw I*provisions of Chapter 9(commencing witli Section''AM)of Division <br /> 3 of the Business and Professions Code and my license ie in full force and afloat, <br /> License M,_^ 717510 Expiration Date: 1 /31 /04 <br /> Date: 5/02/02 tractor: Cascade Drilling, Inc. <br /> Signature: Title. Operations Manager <br /> Printed names_ Vera apman <br /> WORKERS`COMPENSATION DECLARATION <br /> I herby affirm unefer penalty of pe Bury one of the fallowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain s certificate of ooMU nt to Solt-insure for workers'compensatlon,as provided for by <br /> Section 3700 of time Labor Cada,for the performance of the work for which this permit is issued. <br /> X I have and will maintain workers'compensatlon insurance,as repaired try Sects 3700 d rice Labor Code, <br /> for this performaneo of the work fpr which this permit is Issued. My mrerkers'compensafton insurance <br /> carrier and policy numbers are: <br /> Cour: Alaska National PogcyNumber:'^02EWS30531 <br /> I certify that In the performance of the work for which this pormh is Issued.I shall not employ any person In <br /> any manner so as to become sub)aCt to the workers'cornper"tuban laws of Caldornia,and agree that if I <br /> should t oo me subject to the woriwrs'oornpensatton PrOVISlonem Of ion 3700 of the Labor Code, 1 shall <br /> forthwith comply 4th those provisions. <br /> Date: 5/02/02 Slgrmature• . <br /> Printer(Name. vera Cha an <br /> WARNING!FAILURE TO SECURE WORKER$•C4omPENSATION COVERAGE is UNLAWFUL.AND S ALIL SiJ0.113CT <br /> Af'4 eMPLoYt p TO CRIMINAL PEN&Tif 9 AMID CML rwE$UP TO ONE I4UND1i Q THOUSAND DOLLARS <br /> (Stao,000.),IN ADDrTION TO T"K COST OF COMPENSATION,INTEAEST,ATTORNEY'S FEES.AND DAMAGES AS <br /> PRGYIDED IrJN3?08 LA80It CODE. <br /> I, (stgn�.aGt�7 I <br /> olleer►see!sutimortsae!i+epnsentWva}, <br /> hetresysulkarurs(prtnth Greg McIver <br /> tp sign Oda Satz Joaquin upty Well Permit Appllastlon on my bonalf. I linden tend this authorltfatton is valid for <br /> one(1)year and Is limited to the work Pu^detect on the front page orf this appllc 91% <br /> 5.17-20001110111 <br />