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09/27/2006 16:23 9166385611 CASCADEDRILLIN PAGE 02/04 <br /> • a W4VV4/t71?4 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS; S � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (L.CD) <br /> I hereby affirm that l am licensed under the provisions of Chapter 8(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License#: !11i s ' ® Expiration Date: 1 - 31 - 000 <br /> Date:__q -a -7 `Oi'ocQ e <br /> actor; sca- Q ��T I I I tit r , n c., <br /> Signature: _ Tltte.• ���(V-1E� __�M-+Q,6LA��.i✓� <br /> V V <br /> Printed name: F,Y -Y\'.s 4ega; <br /> WORKERS'COMPENSATION DECiL.ARATiON <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 self-insure for workers'Compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work€or which this permit is issued, <br /> ;O�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 tare; <br /> Carrier: I�� Q&-h 4 policy Numb¢w ®�r��S 3093' <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 of the Labor Code, i shall <br /> forthwith comply with those provisions. <br /> Expiration Date:5 I " 07 Signature: <br /> Printed 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 /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION"R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l' (signature QfC-57 IiCensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Wait Permit Application on my behalf. I understand this authorization Is valid for <br /> One(1)year and is limited to the work plan dated on the front page Of this application. <br /> 8-29-02/Ml <br /> MD 29.4).1•0/)1 <br /> 0/22/04 <br />