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03/18/2010 14:28 91663805611 CASCADEDRILLING PAGE 04/04 <br /> Mar. 18, 4010 :41 PM G, AS ENGINEERING & REDEVELOP No. 0590 P. 7 <br /> San Joaquin County Environmental Health Department Unit IV Well permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in Full force and effect. <br /> License#: 938110 Exp Date: 9/30/2011 <br /> Date: March 18 , 2010 Contractor: Cascade Drilling L . P_ <br /> Signature; C?_k, Title: Operations Manager <br /> Print Name: Paul Snelgrove <br /> WORKER'S COMPENSATION DECLAIRATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensatlon, as <br /> provided for by section 3700 of the labor Code,for the performance of the worK for wh1Cn this <br /> permit Is Issued. <br /> % I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit Is Issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier; American Zurich PoliryNUmber; WC3999959 <br /> I certify that In the performance of the work for which this permit ie issued. I shall not employ any <br /> person in any manner Eo as to become subject to the workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. pate: 10/02/10 Signature: C <br /> PrtntNems: Paul Snelgrove <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SMALL SUBJECT AN MVLOVER TO <br /> CRIMINAL PENALTIES AND CML HNES UP TO$100,000,IN ADDITION TO THE COSY OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR COW, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t. (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) ���,_ - ,to <br /> sign this San Joaquin county Well Pemtlt Application on my behalf. I underatand this authorization 18 va(ld <br /> for ono year and Is llmlted to the work plan dated on the front page of this application. <br /> 8129102!101 <br /> enDW-01 1ua107 <br /> tNELL CEq IAiT APJ <br />