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10/14/2002 10:35 14166385611 CASCADE DRILLING INC PAGE Q2 <br /> 10/.4!249:! 1e:25 20946—118 AGE S T 3CKTUH FATE 0:/.171 <br /> %wolf <br /> r San Joaquin G9unly Environmental Health Department Unit IV Well F'srmit Application Up ternan%— <br /> JO® ADDRESS: PERMIT SMO: <br /> LICENSED CONTRACTORS DECLARATION ( C ) <br /> j i hereby at*irm rnar l am licensed under the provis-ons of Chapter 9 (commencing with Seciran 70001 of(?iw�viart <br /> { 3 c>f tf a Ovsiness and Profs**ions Code acid my license is in full force rind etfec�. <br /> I � <br /> } <br /> Lk er se : Explmtion Date: <br /> Daantrector: C i <br /> I ns. - / - � <br /> Signature' __— Tlite: r ' <br /> � I�rrrt4d name: <br /> 1f ORKERS' COMPENSATION DECLARATION i <br /> ! he(ehy affirm under penalty of parjur/ore of the following declarations: (CHECK ONE) <br /> i <br /> I Flave and will niaintWn a certiti.ate of consent to sell-Insure for workers'comper.s sti+on, as provided for <br /> oy Ser-:'ion 3700 of the Labor Code, for the performance of the work far which Lnis permit is iseuecf. <br /> A ! nave cid wol maintsln workers'compelsatlon insurance,as reg0recl by Section 3700 of the Letrar Code, <br /> for the perfvrma;rce of the work fnr which this permii, is issued, My workers'comperedtiOn insuranco <br /> iGa"ribr and policy numbers aro: <br /> Carrier. .__ � 5� Policy Ntlrnher: _ <br /> certrly that;n the performance of the work for whien this permit is issued. I shell riot employ any person in <br /> i any manner so as to 4ecome subject to the workers'remper,satlon laws or California, and agree that if I <br /> l 5'rauid become st bseet to the workers'Gv npensatior; or cion f Sect on 3700 of the Labor Cade, S shad <br /> ! forthwith comply with those provisions. <br /> Date: + - Signaturo; -..-- <br /> i <br /> l Printed Name: <br /> l WARNING;PAILURE YG sEr-ORE WORKERS,COMPENSATION COVERAGE IS UNLAWFUL,AND&HALL SLBJeC T ? <br /> f AN EMPLOYER Co CRIMINAL PINALTIE$AND CIVIL FINES UP TO ONE HUNDRED T40USAND DOLL.Af" <br /> (S,iao,000.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S CESS,AND DAKIAL�C3 A8 <br /> PROVIDED FOR IN SECTION 3706 OF THE LASUR CODE. <br /> ! AUTHORIZATION FOR OT" ES THAN C-57 SIGNING PERMIT APPLICATION <br /> ! I, kf~a- t' 1 Cl o ev\ a n (slgnatura ft' •57 iicenwid authorised repr9scosav,sq), <br /> "TVkbJ+aUth*fte jpdntnamaj <br /> to sign tiiia Sen JoaquUt County Well Porrnit Appiicsiion On my bohatt. I uneerstend.his a0hariratiart 4 Valid€or l <br /> anC(tj War and is i€mited to t"work pl*n datod an the frOrt page of thin application. <br /> 9-2942 1 MI r. —• — <br />