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I <br />'10/16/2007 10:05 <br />9166301 <br />CASCADEDRILLIN <br />PAGE 02/02 <br />San Joaquin county Environmental Health Department Unit N Well Permit Application Supplement _ <br />i <br />JOB ADDRESS: i PERMIT SRX. <br />LICENSED CONTRACTORS DECLARATION' L�D <br />I hereby affirm that I ant licensed under the provisions of Chapter 9 (commencing with Section 7fl00) of ®ivision <br />3 of the Business :and Professions wade and my license is in fun force and effW. <br />License* <br />Expiration Crate: <br />Date_ 10 �%' 0 77 C tractor_ s Gf� p iZ 1 t.U-1 N Cv t 1 N �'• <br />T-rtle: i r\A . <br />Printed name - <br />WORKERS° COMPENSATION DECLARATION <br />I: <br />I hereby affirm under penalty bf perjury one of the fallowing declarations: (CHECK ONP-) <br />I have and will maintain a e of consent to self -insure for workers' compensation, 1S prodded for <br />T by Section 3700 of the Labor Code, for the performance of the work for which this peimit is issueii. <br />" I have and will maintain workerVGompensafion Insurance, as required by Section 3700 of the Labor Code, <br />for the perroftance of the work. for which this permit is issued. My workers' compensation insurance <br />can•ler and policy numbers are., <br />Policy Number. <br />I cert€fy that in the pert nr nainc othe work for which this permit is issued, ( shail not employ any person in <br />any manner to as to become su to the workers' compensation law$ of Cali€omiq, 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 provi �i )ns. <br />Expiration Date: �{ _C? J S' re <br />' Primed 111arrreR ,.�..... <br />WARNING: FAILURE 1'O SECURE Wb <br />ERS' COMPENSAMON COVERAGE IS UNLAVIFUL,!AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL'PENALTI!ES AND CIVIL FINES UP TO ONF. HUNDRED THOUSAND DOLLARS <br />($400,000.), IN ADDITION TO fHE COST OF COMPENSATION, INTEREST, ATTORNEY.-. FEE'S, AND DAMAGES AS <br />PROVIDED FOR IN sEranoN 3708 OF` •ERIE LABOR CODE, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT AO, PUCATIQN <br />t, (signature &C-57 licensed authorized representative), <br />hereby authorize (print narrme <br />to sign this San Joaquin Cduri.ty Well P*-,mR AppikMflon on my belrari. r understand dins auiroriz tion is vat'rd for <br />year and is limited to the work titan dd on the front page of this application. <br />8-29-021 MI <br />M- D 29 -02 -ODI <br />6122/04. ' <br />I <br />