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12/14/2064 12 50 9166385611 CASCADEDRILLING PAGE 02/020 ' <br /> l: <br /> r <br /> San Joaquin County <br /> Envlronnnental Health Dep$rtment Umt{V We{I Berm{t ApQ{ication Supplement ; <br /> JOB ADDRESS: 3202 W• Hammer Lane Stockton PERMIT SRO' 01040406 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herebyaffirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> license �s in full force and effect <br /> 3 of the Business and Professions Cade and my <br /> License# 717510 Expiration Date 1106 <br /> Date Z ! D Con ctor C aide Dnllrn <br /> Title. - <br /> Signature. <br /> Printed name: non Kinloch <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the fallowing declarations (CHECK ONE) <br /> [ have and will maintain a certificate of consent to self-insure 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 /> 0 _X I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor <br /> Code, y compensation insurance <br /> for the performance of the work for which this permit is issued M workers' comp <br /> canner and policy numbers are <br /> Carver: Alas Natlonai <br /> Policy Number: <br /> I certify that in the performance of the work for which this permit <br /> twin laws issued, I Calan not a, a l ploy <br /> ee that d I rson rn <br /> any manner so as to become subject to the workers' compe <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 Signature: <br /> Date: 5105 <br /> Printed Name: ,. Dan IU loch <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANt]CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1oo,ao0) FOR N ION TO THE COST OF STDG OF THE LABOR COMPENSATION,INTEREST,ATT'ORNEY'S FEES,AND DAMAGES AS <br /> ,PROVIDED <br /> AU HORIZATI N POR OT FR THAN C-57 SIGNING pERIVIIT APPLICATION <br /> 1, (signature of C-67 licensed authorized representative), <br /> heroby authonze(print name) <br /> to sign this San Joaquin County W®TE Permit Application on my behalf. I understand this authorization is valid for <br /> 1-6 one(1)year and Is limited to the work plan dated on the front page of this appllcation. <br />