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03/22/2005 23:15 916638566 CASCADEDRILLING • PAGE 02/02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit:Application Supplement <br /> JOB ADDRESS: 37-S- W' Q71c�f�>n A✓r• PERMIT SIRM <br /> 5746� <br /> LICENSED CONT14ACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) A Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License t. D Expiration Date:Z I_c <br /> Date: ra ''0"!; �ont oc C- CC dr— �/�r r e1 9, rit C . <br /> Signature: / Title: cl7�r D n f �ai7 gq e/" <br /> Printedname: 012 A ca✓Y <br /> WORKERS' COMPENSATION DECLARATIONI <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self4nsure for workers'c inpensation,as provided for <br /> ` by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Ee(tion 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensafion insura qce <br /> carrier and policy numbers are: T / <br /> Carrier: �[ k S r 1 A �4 U� / Policy Number:_OK L Y S�a�•�� <br /> I certify that in the performance of the work fur which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree hat If I <br /> should become subject to the workers'compensation provisions of Section 31'00 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: _DS Signature: <br /> Printed Name: C "", �h ad'e , ct•.� <br /> r� <br /> WARNING:FAILURE TO SECURE WORKERS'dOMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANDS CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMhGES AS <br /> PROVIDED FOR IN SECTION 3706 Or THE LABOR CODE. <br /> AUTHORI N FOR OTNEk THAN C-57 SIGNING PERMIT APPLICATIC N <br /> I, (signature ofC-67 licew,-zd authorized repre:entative), <br /> hereby authorize(pr1 name) /Jr7 / jLa r 4 LU. <br /> to sign this San Joaquin County Well Permit Application on m�nderstand this authorization is +aild for <br /> one(1)year and is limited to the work plan dated on the front page of this appiieatl ' <br /> B-29-02/MI <br /> Etm 29-02-ooi <br /> erz2roa <br />