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_ <br /> - 04/ 06/ 2005 23 : 42 9166385611 CASCADEDRILLING rPAGE 02/ 02 <br /> h4/ bf : %YIVJ:] 1 %: WU - ibbblYl'1 .7ruurc iEe rim <br /> N <br /> 1 <br /> sari Joaquin County Environmental Hosith Department Unit IV Well permit Application suppinmerit <br /> JOB ADDRESS: ��/� PERMIT SR#M <br /> LICENSED CONTRACTORS DECLARATION (1.CDi <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 NII farce and a ct. <br /> License #: .r�� Explratlan Date:A �J <br /> Date : 7 D $� CP raCtOr <br /> Sigriaturo. / Title: <br /> Printed name: <br /> WORKERsil COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> have and will maintain a oettftate of consent to self-insum for workers' eomPonoation, as provided for <br /> by Section 3700 of the Labor Code, for the perrarmance of the work for which this permit is Issued. <br /> I have and will maintain workers' eompansation Insurance, as required by Section 8700 of the Labor Coda, <br /> for the performance of the work for which this permit Is Issued. My workers' compensation insurance <br /> carrier and policy rumbers are: <br /> Carrier: hAw4 O* & Poticy Number, <br /> I certify that In the performance of the work for which this permit Is issued, I shell not employ any person In <br /> arty manner no an in become subject to the workers' compensation laws of California, and agree that if I <br /> should become=mpl subject to the workers' compansatien pro Section 3700 of the Labor Code, I shall <br /> forthwith campl � hsavlgnat <br /> Expiration Pate; _ � .�9lgnatum; <br /> Printed Name: ze � <br /> WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE is UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANG CIVIL FINES UP TO ONE HUN13RFZD THOUSAND DOLLARS <br /> IN <br /> DN <br /> P�RpV1I,1Eb7FOR IT CT ON TO THE a7 B COST OFOF THE LA®OR NSATCODEION, INTEREST, ATTORNEYS PEES, AND DAMAGES AS <br /> IHORIZq ON F OT EA2 THAN C-57 SIGNING PERMIT APPLICATION <br /> ZZA�� - - (signature ofC�47 firgnsad <br /> aauu'thorized presentative), <br /> hereby nutitoelzo (print name) �iGf6�/"�Grf7� � ✓� G- dj <br /> to sign this Son Joaquin County Well FarmitApplication on my behalf. I understand this authorization In valid for <br /> Waft) year and In limited to the work plait dated on thn front maga of this appliaatiom, <br /> 8.29421 MI <br /> 611D 29,02,001 <br /> 6122104 <br />