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09/27/2006 16: 23 9166385611 CASCADEDRILLIN PAGE 02/04 <br /> WJ VV4/411#4 <br /> San Joaquin County Environmental Health Dep <br /> �a <br /> �rtmen <br /> ntt Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �— Z �� '1 IC-1 .� JJ(5:�� • PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that i 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. 1 <br /> License M -7 1 -?S 1 CU Expiration Date; ! Q 8 <br /> Date 'D�7-7 `O(o Co ractor: s c a- 1p <br /> Signature. Title: �1�C m ��j '� <br /> F1� J e_. 1" i L "'�.l'"r <br /> Printed name: G-��e� �Iti�t�,YYE'. <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 self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> i have and will maintain workers'compensation insurance,as required by Section$700 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: <br /> Carrier: lack-A. Qm ' ioKa-1 Policy Number, 53053, <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:r�` " ' 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 PINES UR TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000•),iN ADDITION TO THE COST OF COMPI_NSATION,INTEREST,ATTORNEY'S FIFES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION"R ®Tf•!ER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 (signature ofC-S7 licensed authori-5L� lk�7 —� zed representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> tine(1)year and is limited to the work pian dated on the front page of this appilcatlon. <br /> 8-28-02/MI <br /> Win a�.cz•ari <br /> 012VO4 <br />