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03/10/2004 10:40 19166385r CASCADE DRILLING PAGE 02 <br /> 03/10/2004 10:04 209467; tGE STOCKTON N~at bllbL <br /> vis �- <br /> San Joaquin County EnvVordnantal Meatal Dapar"rlt Unit W Well Permit Application Supplernont <br /> JOB ADDRESS: ZZIg, 0• (. )LLivK., C yy /17�PERMIT SRO: CC)3 -7 <br /> - <br /> LICENSED CONTRACTORS DECLARATION (LC,D) <br /> I hereby affirm that I am ltenaed under the prcmziom of Clixgter 9(commencing wit Section 7000)of Dn ision <br /> 3 of tr?a Ousln/nom�and Profesamns Code and my licAnse is in NO forst and affect. <br /> I_�CefM e: `1 )- r 3-1-?15( 0 Expiration Da L;3( �_�U <br /> Date -,�` ontractar. <br /> Signature: Teti.: r(I^ <br /> Printed name: Ol <br /> WORKERW COfl PENIA T ION DECLARATION <br /> I hereby emrm under penalty of parjvry one of t'9®follovrir>g declarations: (CHECK( ONE) <br /> t haus and will maintain a certificate of consent to a�e'4-insure for wortcsrs'wrrspe�nSptign,as provklec or <br /> by Seetlon 3700 Cf the labor Code,for the performance of the work f6r which tr,i i permit is iswed. <br /> I rem and will maintain workem'compensation insurance,as requinad by Soaticut 3700 of the Labor C)de, <br /> for tree per km.ancr of the work for which this permlt 19 isauad. My workers'coml:ensaVon Instirence <br /> carrier and policy numbers e: <br /> j Carrier: ( gyp(/ � R policy Nr:mbor. <br /> I cartify that in the perN",ante of thework for which axis pex'tnit is issued,1 shall not employ any Pers,-,in <br /> gny manner se as tv bpm@ subject to the wo&ara'Cnmpenswtion laws of Cafif:,rn*and agree that if i <br /> 0-9VIC 0000me subject to the workers'conpensaW 0r13 Saction 3700 of the lsbvr Code, 1 s hall <br /> fcrthwlth comply Kith those provisions. <br /> Cat.: ��` )� d� Sigrw4uro: <br /> E Printed!fame: <br /> 1 WARINANG.,FAILURE TO$99UR1s M4CJs'i EAS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SMALL Suaj ECT <br /> AN P MPLOYER TO CRIMIINAL PENALTiO AW CIVIL FINES UP TO CN€HUM AED THOUSAND DOLLAns <br /> {NOA,Ap0.1,IN ADOMQ"To JNr3 CObT OF QQMPtEI'i.SAT*N,INTEaREST,ATToRNSY'i rteS,AND DAMAGES AS <br /> PROVIDED FOR IN 3ECT1t314 9708 OF THE LAtlC+ft CODE <br /> I <br /> i AUTHO T19N FOR Or=THAN C-87 SIGNING PERMIT APPLICATION l <br /> 1 <br /> 4 -tsignatur'e cM-57 liGltrrs■d eutyorfzed nmpr+eSer+tai ivel, <br /> hereby.uthor4xerpd amep <br /> tv Sign this San J020111 Cornty Mhli Pomit Application on eery bahaif. i undo-stand this Authvrisetton is valid,or <br /> t o�11)year and is lfmtted to the work plait elated on the troni rragq of o jo mpptigmu9n. { <br /> 0-29.92/Cf111 <br />