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11/29/2007 16:40 9166385611 CASCADEDRILLING PAGE 01/01 <br /> h <br /> San Joaquin County Environmental health Depattmont;Unit IV Wali 1rOi'ifl'lil'r;-AlpPlinatitm SUPPIPrnent <br /> JUS ADDRESS: 14WOLLL 501ALiO(z1 i 51., S61<6m PERMIT S►R#: <br /> LICENSED CONTRACTORS DECLARATION LSD <br /> I hereby affirm that I am Iican4wad under the provisions of Chapter 9(Commencing with Section 7000)of Division <br /> 3 of the BL(Nnerz and Profesrsie/n"ss Code and my license is in full force and effect. { �7 <br /> License Expiration Date: ` 1 1 <br /> Data: ECI Q Contractor: ` C Q r�e V j i r)C <br /> Signature= /�7 iitie: <br /> Printetf name: <br /> WORKr-R$l COMPENSATION DECLARATION <br /> I horOy affirm under penalty of perjury one of the foilowing declarations: (CHECK ONE) <br /> I have and'Mil maintain a certtfirote of consent to self•Insure for workers'cornpcnsation,ad Pwdled for <br /> by Section 3700 of the Labor Cade,for the performance of the work for which this permit Is issued. <br /> y I have and writ maintain wormers'compensatlon insurance,as required by Section 3700 of the Labor Cods, <br /> for the performance of the work for which this permit Is issued. My workers'compensation insurances <br /> car'rior and policy numbers are: 1 A , <br /> Carrier; A N �� r Policy Number: 07 FWS �30r-5 <br /> I certify that in the performance of the worm for which this permit Is Issued, I shall not employ any porson in <br /> any manner so as to become subject to the worlmrs'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 cif the Labor Code,I shall <br /> forthwith comply with those provisitns, <br /> Expiration Date:15 0 S Signature: <br /> Printed Nano: �� J�.f U L KA, I � C) <br /> WARNINC4 F AIL,tlRe To SECURE WORKERS'GOMPENSAMN COVIMAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AM EMPLOYER TO CRFMINAL PENALTIES AND CMI.FINES UP ra ONE HUNDRED T14OUSAND tsO"ARS <br /> ($100,000_►.IN ADCriMN TO THE COST OF COMPE=NSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A3 <br /> "ROIADED FOR IN SECTION 3TOG OF THE LABOR CODE. <br /> ,AUT RIZATION FOR OTHEQ THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (Signature OM-iso lfrmmrad authorized rspnmantative), <br /> hereby authortae(print nmmoo) SCC4 a-*VngS Il t s Envy t iif s <br /> ro sign this San Joaquinn Caimty Wall Permit Application on my behalf, I undamt%nd this authortr.Wan Is VQild for <br /> ane('f)yssr and Is IlMltad to the work plan dated on the front page of thin application. <br /> a-2s.p21 MI <br /> >;iim z4-02001 <br /> e=/M <br /> U/Z0 30vel AT`ibb ON sn.Lvais 50es9/8g8 8UZq-T /_007,/67/T.T. <br />