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04/26/2004 14: 06 19166385611 CASCADE DRILLIN4I' PAGE 02 <br /> 114/25120©4 14:21 2634F7�8 <br /> San Joaquin County Fnviroreful" l HealthDepartment; Unk N Weil Permit ADPhcetlon 8uPpleme t� <br /> [JOB ADDRESS: cnJ7S W NRS, PERMIT <br /> I 5p cnKTmnl � �} <br /> LICENSED CONTRACTORS DECLARATION (L&,) <br /> 1 Imreby afsrm that I am licenced under the provisions of Chapter 8(oorrmrmcing with SCOW 7000) of Div*ion <br /> 3 of the Business and Professions Code and my license is'n NII force and Gffsct <br /> ��'2"�1 `� ( ) s( Q ExpiratOn 1) 0 <br /> License 0: ^�.._S - 1 _ <br /> Dater_-13�ConvWor; ('� <br /> Signature: - <br /> Tide: <br /> Printed nsm!' <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affrm under penalty of perjury one of the following dertatations: (CHECK ONE) <br /> I have and wilt maintain a tenlflcat13 of consent to self•Insure for workers'comptmsetton,*0 prodded `Or' <br /> Uy Section 3700 of ins Labor Code,for the performairm Of 111113 work for WhICh it pannll is Issued. <br /> I have and will maintain workers'compensation Insurance,as regvirsd by Sectiol• 3700 of the Labor C>de' <br /> for the performance of the work for which this permit is issuedfly workers' comoensatlon insurance <br /> carrier and policy n bets a <br /> I Caniar:_p_� j,311L1n1S policy Number: <br /> o13rtif j tnet'n the parforrnonca of the work for which Into oefmif is issued, I Shan not employ any perst n in <br /> any manner sq as to become svopa to the wD1'kera'compensgticn law$of CSI!fo-nip, and agree the:! I <br /> i shovld tlacome subject to the workers'compensation prOV1510 c!! 37 df the Labor Code, 1::haU �I <br /> fcrt�hlwi�N comply with those provisions. <br /> Dab: "lu'E��,Q Signature: — -- <br /> Printed Name: <br /> WARNING:FAILURE 70 SECURE WORIGRE'COMPENSATION COVERAGE M UNLAWYUL,AND SMALL SUS,IECT <br /> AN EMPLOYER TO CRIMINAL PENALT194 AND CIVIL FINES UP TO ONE HUNDRED THCIVOAND DOLLARS <br /> (5100,000.1.IN ADDITION TO THF COST OF OOMPENBATIpN,INTEREST,ATTORNEY'S FEES,AND OAMAQES AS <br /> iPROVIDED FOR IN SECTION 3706 Of THE LABOR CODE <br /> AUTHORIZATION FOR 07HEft THAN 0-57 SIGNING PERMIT APPLICATION j <br /> VGCck- G I'Lc2�✓'t/�r�� r ,,,_(signawnorcd711cemedsuthorleednpresenr]tive1. <br /> hereby eutnorks Ipnnt name) /'M or/�-I�CuV14.0Cr -.----.----------"1 <br /> to sign O+ia Sm Joaquin County Well Permit Application on MY behalf. I understand thkf authorization is Valid for <br /> olio(1)year and is limited to the work pion dated on the hent page of thre application, <br /> 8-7e-021 MI _ .,.__ --j <br />