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04/28/2004 13:21 1916638Rr-",.1 CASCADE DRILLIh," xNC PAGE, 02 C <br /> V <br /> FS,,n ,qn County Envirertmerrtal Health Department Unit IV Well Permit APP(icati°n Supplement <br /> pD 3D <br /> SS: r I. -fh PERMIT SRN`20LICENSED CONTRACTORS DECLARATION that I em licensed under the provisions of Chapter 9 (commencing with sedion 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. j <br /> License : (~ `217 Si Expiration Date: <br /> Date' O Cont dor: <br />� TWO: , <br /> Signature: f <br /> Printed now: I <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to saHJnsure for workers'Compensation, as Primed for <br /> by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. MY workers'compensation insuranCe <br /> carrier and policy numbers are: I <br /> � <br /> 1 `l <br /> cnh \ Palley Number: N <br /> Carrier. <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Calitomia,and agree that if I <br /> should become subject to the workers' compensation provisions Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Signature: <br /> Dant: <br /> Prirnbad Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000•),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> !` AUTHO TIO FOR QTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C47 IfcensW authorized rep wartativs), <br /> hereby suthodze(print e)to sign thla San Joaquin County Well Permit APPllcaaon on my behalf. I understand this adnrori:allon is valid for <br /> z <br /> one(1)year and is Ilrrdtad to the Werk plan dated on the front page Of this application. <br /> 349-03!MI <br />