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IW2007 12:09 9166385611 CASCADEDRILLING PAGE 02/06 <br /> ;IfllNeafth <br /> S4111,100cluinCOu"tYEnvironment :;7.; <br /> e IV Well P rM <br /> PPle M <br /> JOB AbORESS: �D2-1-12- it Ap�plicaqon SUppledf <br /> PERMIT sR#: <br /> I hereby afrlrm LICENSED CONTRACTORS DFCLARATION (k_CD) <br /> 3 Of the that 1 am licensed under the provisions <br /> Business and Profession, lis'ona Of Chapter 9(commencing with Section 7000)of Division <br /> License#: -7 1 -7 "- I Code and My license is in full force and effect <br /> Date: 119 f0-7 Expiration Date: 3 o <br /> Contra <br /> SignOture. J> <br /> e- '( ;,1_6, <br /> Printed name: gr(V Title: <br /> WORKERS'COMPENSATION DECLAMATION <br /> under penalty of perjury one of the <br /> Irm <br /> I hereby of f <br /> have and will maintain following declarations: (CHECK ONE) <br /> 00ofthe a certificate of consent to self-insure for workers,compensation, as provided for <br /> < by Section 37 Labor Code,for the Performance Of the work for which this permit is issued, <br /> I have and will maintain workers,compensation insurance,as requ' <br /> .red by section 3700 Of the Labor Code, <br /> for the performance of the work for which this <br /> carder and policy nunibers are: permit 11S issued. My workers,compensation insurance <br /> Carrier: I <br /> Policy Number:-0(0L>W5: <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 California, and agree that if I <br /> should become subject to the workers'compensation Provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Date! ' ""off .signature: <br /> PriftwNimi: E�7L-f-C.4- fd=,11/1.44 <br /> WA,;MG;FAILURE To SECURE WORKEERS,COMPS4SATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER T 0 CRIMINAL PENAL1112-8 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> fS100.000.).TM ADDITION TO TRE COST OF CO TION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 2706 OF THE LABOR CODE. <br /> AUT14ORIZATTION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. JA!:= � .3= -(Signature ofC.57 licensted authorized representatives), <br /> hers-by authorize(print nan 19e,' <br /> to sign this San Joaquin Covnly Well PerrWit ApprTcafi*ln on my behalf.. I understand this authorization is valid for <br /> orwe <br /> f`)year and is IirnW W the Watk P12M dated On the front page of this application. <br /> 3-29-421 Ml <br />