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0.6/.18/2063 16:16 19166381 CASCADE DRILLIh NC PAGE 03 <br /> 26/19/2M 16:30 20946, 9 AGE STOOMN PAGE 02/02' <br /> I <br /> San 40&quin . unty Environmental Meatth Department Unit IV Well permit Appilootion Suppiemont <br /> I <br /> JOB AUURE*95: /SO) Lv. -r PERMIT SRO- <br /> ` LO T C_ot <br /> ;UCENSED CONTRACTORS DEC • RATION eZLC�I <br /> i <br /> I hereby affirm that I am lioms5ed under the provisions of Chspter 9 cornrn9nvhV with Section T000j of Divtaton <br /> 3 of the Business and PmfesSions Code and my license is in lull for a and effect. <br /> 1 Lacense � - 7 Expiration fete __ — _ `t <br /> Trate.� CrJntraclor. ` <br /> i <br /> Signature• nth `` <br /> Pnntod name; <br /> WOR1ClrRS'COMPENISATION 019CLARATION <br /> I hereby effm uridar penalty of perjury one of the follav Ing dsciarat ns: (CHECK ONE) <br /> I have and uriill rtta(ntain el i WKmate of consent to M114neure f warkers'ctwnpensaharr,as prvvided for 1 <br /> by Section 3760 of the Labor Code,for the perfonmance of the for which this permit A issued. <br /> +� I have and Will maintain workers'cornoonsatitm insurance,as r4 quired by$action 3700 of the Labor Code, <br /> for the perfarrnanve of the work for which anis permit is Issued, w9rksm'o rroensation irmu anee <br /> E <br /> carrier and policy numbers are: <br /> Cilrrler: g4101n6l <br /> Policy MUrhbw.. <br /> I certify that In the performance of the work fir which this permit is issu ad, I shall not onrploy any parson in <br /> any manner sd As to became subject to ttt*Yvarkers'emYtpensat an laws of Ceailfomia andj <br /> ogre+that-if 1 <br /> should bacomei subject to the workero'compensat n ons of Inn 3700 of the Labor Care.I shell i <br /> furthwitn comply with thane prcvb on. <br /> Prin�d Nsrlrrtla: <br /> WARNINU:FAILURE TO SECURE WORKERW OMPENSATIONOE 13 UNll.AWFUL,AND MftL VUBJECT <br /> AN CM101,0YER TO O141MilINAL P IENALT11113 AND CML,FMB UP TO I1t1Me1 WO THOUSAND DOLLARa <br /> (3100.000-),IN AOorhON TO THE(:OST OF[oNI1P'voArm iNYM n ,AT7 r*ftff$,ANIM IDANME9 A$ <br /> FROVIoab Pon IN:IiEQnON 3706 WTIW 1 At'M GODS <br /> AUTHO FllkoE THAN C-57 SIGN INC PERMIT APPLICATION <br /> 7! (signetu ofC-5711nenard authorlaad reprraentstiYol, <br /> hereby aumorla•(prone 0.1 <br /> k v + V 1 <br /> J <br /> to sign tray PIM 466ciuin G*imty.YYeli Permit Application an my behalf. undsrstand this authaN:ration is valid for <br /> i one(1)yrar and 11#Med so the work plan daW 4n aha front pap of alpptkauaa. <br /> 6-20-d4 l M1 <br /> I <br />