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01/03/2003 13:24 19166385F11 CASCADE DRILLING LNC PAGE 02 <br /> e1/@'-W2QQ3 13:38 ?6946 6 AGE STR:k:TOH i e2itu <br /> we <br /> r San Joaquin County Environmental HOW Depar"anmit t Unit IV Well PerApplication Supplement <br /> J09 ADDRESS: I� 7Y9 4). -roY.& rev .LS i PERMIT SRli32 33 <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereey affirm that I am licensed under rile provisions of Chapter 9 (oommencIng Wllrl Section 7000)of Division i <br /> 3 of the Business and profeastons Code and my license Is in full force And effect. <br /> t <br /> License# �'59�� ) __ Expirat.ion hots- _/;c3L Q <br /> Date:�� C tractor. C p _� <br /> Title (` r <br /> i <br /> Signature: - 1 I <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under panahy Of perjury one of the fo'towing dec!eratums. (CHECK ONE) <br /> i nava and will maintain a certificate of consent to self4ri tot wor"kers'Compensation,as providtld for <br /> by Section 3700 of the Labor Code,for the performance of the work for wNch th s parmil is issued. <br /> 1 have and wit mairtain workers'compensation Insurance, ea required by Section 37CO of the Labor Code, <br /> for the performarwa of the work for which this poemlt is ;slued. My workers'eampensetion :nsurenoe <br /> carrier and Policy n1ulmbers are' �-t / <br /> Carrier: �,�„] �•^(] 1 Vf-n.a.�.._-...,Policy Numhvr.��t„_�1 G �� ,1Q7-� <br /> I -amity,.hat Jr, the performance of the work for wnich this permit is issued, I shall not employ any person In <br /> any manner bo as to become subject to the workerscompensation laws of California, and agree that it I <br /> Should become subject to the workers'compensat!on rovislo of Section 3700 of the Labor Cede, I shall <br /> forthwith comply with those provisions. <br /> Date; <br /> Printed Name•. Y�1� <br /> I <br /> ! FAIL <br /> ANN IMPLOY 70 CRIMINAL E ALTIE#AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> LL U ECT <br /> LARS <br /> R <br /> (51 go.000.j,IN ADDRION To TH@ COST OF COMPENSATION,INTEREST,ATrOoNiff" FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3100 OF THE LABOR CODE. <br /> AUT RIZ TION FOR QTHE THAN C-37 SIGNING PERMIT APPLICATION i <br /> L _ --}'� _(rignaturr ofC-67 Iicangd ruthortced rapresw atwel, <br /> henby autnorlLe nt nanw) //m �L��Ak' - —. , <br /> to sign this San Jo44uin Guunty Wall Permit Applleaaon on my Uehdi. I undenta <br /> rd this autho#1*60 n u valid for <br /> 0110(1) year we is Iimilad to the work plan dated cn the hank POO&of this application. <br /> ase-g2/ <br />