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05/02/2002 12:33 19166385611 CASCADE DRILLIJ INC PAGE 04 <br /> M 09:52 FAA 1 deal 0441, oz......-�....•� • <br /> San Joaquin County Envlrenmantal Health Serviens, Unit IV Well Pertnit Appllestlen Supplement <br /> JOB ADDRESS: `/1 '17 Al, wca i I-ri. £ h,r rof PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)at Oivlsion <br /> 3 of the business and Profmiona Code and my license is In full force and effect. <br /> Lleense r: _71 7sl_a__ExpIratfcn Date: 1 / 31 /04 <br /> Date- _q,,4�..Contrjoor Cascade Drilling, inc. <br /> Signature: Title: Operatioris Manager _ <br /> Printed name: Verman <br /> W RKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following dndarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate el consent to self-Insura for workers'eompensatign, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is saved. <br /> X I have and will maintain wo(kers'compensatian 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'compensat--ion insurance <br /> carrier and policy numbers are <br /> Cartier: Alaska National polfoyNum6er: 02EWS30531 <br /> _1 certfy fiat in the porformanoe of the v4rk for which this permll Is Issued, I shelf not employ any parson In <br /> any manner so as to bawme subject to the workers'compensation laws of California,and agree that H I <br /> should becoma subject to the workers'compensation pr ons of action 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Data: 5/02/02 Signature: lk -- <br /> Printed Name: Vera ChapUn <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML RNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),W ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR sa SECTION 3 <br /> 1 ^ a) 6 OF THE LASOR CODE_ <br /> _ b71ioensed eWhoAted repepntstiva),(sigature o1C <br /> GregMcIver <br /> harobysuthoritepdnt <br /> to sign thla Son Joaquin County Well Permit Application on my beha8, 1 understand this euthoricatdon Is valid for <br /> one(1)year and Is Ilmnad to the want plan dated an the front page of this aPPltaatlon. <br /> $,17-2000!Yt --- <br />