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05/01/2003 11:32 19166385611 CASCADE DRILLING INC <br /> 099 31'03 THL' 11:31 FAA 1 016 581 0430 <br /> PAGE 03 <br /> ✓rd %.W <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: -QqmE; �� . PERMIT SR#: <br /> 9CDC&*6)0 114Q <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full forte and eftect. <br /> License*-. C„�r? 1"751 CS Expiration Date: 1 - 31 - O C/ i <br /> Date: 51 — OVCont ctor: 0.0 15�0Q C,I Q I r% _ <br /> Signature: Title: 1 t 1 C <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certiflcate of consent to self-insure for workers'compensation, as provided for by <br /> Sec'.ion 3700 of the Labor Code,for the performance of the work for wniCh this permit I3 issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Lacor Cade, <br /> for the performance of the work for which this permit Is issued. My workers'cornpensatlon insurance <br /> carrier and�ocilcy numbers are: <br /> Curler. Policy Number._na ELt)`)Sm 21 !� <br /> _I certify that in the pertormenCe of the work for which this permit is issued,l&hail not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California.anti agree that it I <br /> should bec"a sabject to the workers'compensation s of S ion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: r" Signature: <br /> Printed Narno:_NLar�__.. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND MALL SUBJECT <br /> AN EMPLOYER TO CIRIMINAL PI NALTICS AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> wow.QEf).IN FOR ION TOION HIE COST OF OF THE LABOR PCOD£ON'INTBRMT,ATTORNEY'S FEES,AND OAMAOE9 A3 <br /> PROV <br /> 4 (signature OC-57 floensed suthorltsd rsprasaRltattiva), <br /> heresy authorise(print name) - —_ <br /> to sigl+this San Jeaquln Courdy Wall Pertnit AppllesNon on mr behalf. I understand Il+is authorization Is valid for <br /> ons(1)year and is ItMItsd to the work pian d.t.d on the front page of this apptlea110n. <br /> S-17.2000 i MN -- <br />