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09/05/2002 16:56 191663817-'1 CASCADE DRILLING 'NC PAGE 02 <br /> 85/17/2891 13:36 20946f,,,,.,,3 FIFTH FLOOR � PAGE 92 <br /> San Jo&Wuln County Environmental Health 5ervkeC unit IV Well Permit Applioat Supplement <br /> JOB ADDRESS: 1,1,3 Z-i WNW I �' 1 PERMIT SRO. 0O-'189 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby aKi.Tn that I am licensed under lqe previsions of Chapter 9 (commerong YA%h Section 7000)of Division <br /> 3 of the Business and Profession^s�Code end my license is in full force and effect. <br /> License t I Q Expiration Date: �3,�..--�-L <br /> Date: <br /> Signature; t _ Title: t� 1 ads <br /> Printed narms- eo <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under peralty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a Certificate of consent to salf-Insure for workers'compensation, as provided for by <br /> Sectlon 3708 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 3700 of the Labor Code, <br /> for the performance of the work for wh!ch this parm l:is issued. My workerii'compen#ation Insurance <br /> carrier and policy <br /> numbers are. <br /> Carrier: i) , � --� VVy �� ( O ,l ' Sr <br /> I certify that in the performance of the work for which this permit is Issued. I shall not annploy any person in <br /> any manner so as to become subject to the workers'compensation taws of California,and agree that if I <br /> should become subjact to the workers'compensation provisiors of SQCtion 3740 of the Labor Cody, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: _1 C1� C YN-\ Ck �1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAOE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CiVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (6100,000.),IN ADDITION TO THE COST Of COMPENSATION,INTEREST,ATTORNEY'$FEE$,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 8709 OF THE LABOR COVE. <br /> I, f ^a C r 'Q Q r\. (C•57 licensed suthortsed representative),hwvtW <br /> authorize �[ T7 _ r • ) c D aCA S I <br /> I to sign this Sen Joaquin County Wolf Permit Application on my behalf, I understand this atrt!lorization Is valid for <br /> on*(!)year and It Ilfnitod to!h#work plan dated an!!11 front page Of this application, <br /> 647,2000!Mi _ J <br />