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£ r r 't `* <br />t51�5, 06:31 9166325611 CASCADEDRILLING PAGE 02/04 <br />I L�fla/2E0b," 14:05 9169610430 5��•:i-ir �.� <br />San Jcaqu'nnC�C0Unty E ira"Mental Health Department Unit Id Well PerMiit Application 5upplemenL <br />JOB ADdESS; �Zp PERMIT SR#: ria zL 3 <br />LICENSED CONTRACTORS OF-CLARATION (kl�-D) <br />I hereby affirm that I am licpnsad under the provisions of Chapter 9 (commencing with Section 7000) of Dlvieion <br />3 of tha Business andel Professions, Cade and my license Is in full force and effect, <br />Llcensm #F l7J Expiration Detect: / O <br />Date: d� Co actor, C/cz-�--/LGf/f��. <br />Signature: Title: <br />Printed name: , 204 <br />WORKERS'COMPENSATION DECLARATION <br />I hereby firm under penalty of perjury one of the fallowing declarations: (CHECK ONE) <br />_ ( have rind will maintain a certificate of oonsent to self -insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />have and will maintain workers' compensation insurance, as raqulmd by Section 3700 of the Labor Code, <br />for the performance of the work for which this pArmit is Issued. My workers' compensation Insurance <br />carrier and policy numbers nrt <br />Carrier: �/liL�i¢ /virPolicy Numbor: 0:5z� <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person In <br />any manner so as to become Subject to the workers' compensation laws of California, and agree that if 1 <br />should beoQme subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with tho5ri provin;ons, <br />Expiration Data,, �� Signature: . <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPEI+ISATION COVERAGE I$ UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL, PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S1 00,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FOES, AND DAMAGES AS <br />PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE, <br />ORIZATION F <br />hereby authorize (prink <br />THAN C-57 SIGNING PERM!T APPLICATION <br />ature ofC-57 licensed authorized mpmsentatiive), <br />to sign this sari Joaquin County Well Penult Application on my behalf. I undemtancl thin authar'Ization 19 valld for <br />one (1) year and Is limited to the work plan dated on the front page of this Application, <br />Br ID 29422 001 <br />6222M4 <br />