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110/16/2007 10:05 9166385;611 CASCADEDRILLING PAGE 02102 <br />San Joaquin County Environmental tfeatth Mpartrnent Unit LV Well Permit Appli0tion Supplement <br />JOB ADDRESS"6 f fe A/ 111 -t/r`e 7 h' PERMIT SR#; <br />LiCE SED CONTRACTORS DECLARATION L D <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business :and Professions Code and my license is in fun force and effect. <br />1-09 <br />License <br />---711-7 Expiration Date: <br />j <br />1 Q_ D tractor_ �~ G'' t?' <br />Date: •rte-- -- <br />Title- M C -P F- - <br />Printed name d hl \j A-P-A-rA 1, L' 0 <br />WORKERSCOMPENSATION DECLARATION <br />i <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK. ONE) <br />1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for <br />by Section 8700 of the Labor Code, far the performance of the worts forwhich 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 ofthe work for which this permR is Issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier- At, Y -Pr Policy Number: D -7Vii ;� L30 <br />I certify that in the performance'lof tws he work for which this permit is issued, 1 shall not imploy any person in <br />any manner so as to become su4;ct to the workers* compensation laof Cailfomij-, and agree that if i <br />should become subject to the wor'keW compensation provisions of Section 3700 of the Labor Code, I shalt <br />forthwith comply with those provir�ions. <br />Expiration Date: 'j r � ®0 <br />Printed Name.— TO K1111% J A-PA"m l 1-- - <br />WARNING: FAILURE TO SECURE WORD ERS' COMPENSATION COVERAGE IS UNLAVVFUL,IAND SHALL: SUBJECT <br />AN EMPLOYER TO CRIMINAL_ PENALTIES ANI? CIVIL FINES UP TO ONE HUNDRED THOUSAND DOUARS <br />($400,000.), IN ADDITION TO THE COST' OF COMPENSATION, INTEREST, ATTORNEY' FEES, AND DAMAGES AS <br />PROVIDED FOR iN SECTION 3706 00 t.HE LABOit CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin Courtity Well Permit AppW ation on my behaff. r understand this authorization is valid for <br />I <br />one (1) year and is limited to the work elan dated on the trent page of this application. <br />8-"-021 MI <br />MID 29.02.001 <br />=2104 <br />