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110/16/2007 10:05 9166385-611 CASCADEDRILLING i PAGE 02/02 <br />San Joaquin County viroran. gral Health Department Limit Iv wen Permit Applid�afiw Supplement <br />row)&/ <br />ADDRESS: PERMIT SR#: <br />JOB AD S <br />, <br />LICENSED CONTRACTORS DECLARATIONM—Q) <br />I hereby afnrm that I am licensed ur�er the provisions of Chapter 9 (commencingWith Section 7000) of Division <br />!S of the Business and Profhs6t0ns lode and -my scanse is in fun force and eflect, <br />-7 if -7 Expiration Date, <br />License <br />S CA Dr_- [> 1 12-1 1,,L- I N d:;, N C. j <br />Date: Co6trador <br />1 Printed rmmw. j A <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm UnIdeir penally hf perjury one of the following declarations: (CHECK ONS) <br />i have and will rnaintaI6 a ceffe of consent to seff4rism for workeiworkers'compenation, as prori1ded for <br />by Section 3700 of th Latcr Code, forthe pedorm. nce of the wort rorwhich this peirrilt Is issued. <br />90 <br />I have and will maintain *orkerV compelwatida Insurance, as reWred b37of the Labor Code, <br />r <br />y Secoon <br />for the perfo�nance ohh6 work for which this permll'is issued. My workers' co�.npen4ation insurOnce <br />carder and policy numbeis are.. <br />4 <br />-7 IF V <br />carflei%6 Paricy Number. 0 <br />I certify that in the perlormancoo the work fbrwh*ch the permit is Issued, I shall not imploy any person in <br />to b6corne to -the wfterst. compensation [am of COINW141, and agratthat if I <br />any manner to As to b6c6rne s�L <br />o' provisions of Section 37 00 of the Labor Code, I shall <br />should become subject t6 the workers' oompawaff n p <br />forthwith comply with thosieproN& ions. <br />Expiration Date::. rij natal*'0000�-- <br />-W �_f A-1ZA-M <br />Prinibid, T <br />WARNING: FAILURE TO SECURE WOI�KERS' :G=PENSATION COVERAGE IS UNLAVIFULIAND SHALL SUBJECT <br />AN EMPLOYER Th CRIMINAL.PENA0125 AWV CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(SI 00,00&), IN ADDITION -fb I'ME Cd& OF COMPENSATION, INTEREST, ATTORNEYS F EFA AND DAMAGES AS <br />PROVIDED FOR IN SECTIONV00 00 1!HE LABOR C*Dr_: <br />AUTHORIZATION FOR bTHER THAN C-57 SIGNING PERMITAO, PLICATI bN <br />($10nature afr—ff licensed authorized representative), <br />_ <br />hereby authorize (print "allie): <br />to sign this San Joaquin 06u rity Well. P`erMlt Applhmflon on ray bebaff. I understand tins "rk-ran it valid for <br />one (1) year OW is limited to the work Stan dated on thefr6nt page OF this OPPlication. <br />8-209-021 MI <br />MLID 29-02-00I <br />6)22/04. <br />