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04/28/2004 13:21 1916638 l a CASCADE DRILLIt/ NC PAGE 02 <br /> San Joaquin County Ell <br /> vi Health Department Unit IV Well Permit Application Supplement <br /> 00 5 I <br /> PERMIT SR#: <br /> JOB ADDRESS: �h �00 * _ <br /> i <br /> LICENSED CONTRACTORS DECLARATION LDS <br /> ( C <br /> I hereby affirm that 1 em 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 full force and effect. <br /> ^ <br /> License 0: <br /> Expiration Date: <br /> Date! C Cont ctor: <br /> �— Title: <br /> Signature. <br /> Printed name: <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 lance of the or w foe s.co this permit t is issueed for <br /> by Section 3700 of the Labor Cade,for the pe <br /> 00 OS the Labor Coda. <br /> I have and will maintain workers' compensatlon insurance, as required by Section 37 <br /> for the performance of the work for which this permit is issued. My workers compensation insurance <br /> canner and policy numbers areat I <br /> Policy Number: <br /> Carrier: <br /> I certify that in the performance of the work for which this permit is issued, I Shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Califomia,and agree that if I <br /> compensation provisions Section 3700 of the Labor Code, I shall <br /> should become subject to the workers' <br /> forthwith comply with those provisions. <br /> Expiration Signature: <br /> Date: 5- j-Q ^^ <br /> Printed Name: <br /> COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> WARNING:FAILURE TO SECURE WORKERS' <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=1ep, PLO INA O CRIMINAL <br /> TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHO TIO FOR pTHER THAN C-57 SIGNING PERMIT APPLICATIONii <br /> (signature of G47 licensed authorized representative), <br /> ..nllnr- <br /> hereby authorize(Wirt n e) <br /> to sign this San Joaquin County Well PartMt Application an my behalt. I understand this authorize is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this appliwtlon. <br /> i <br /> . 3-19-05 f MI <br /> c <br /> T � <br />