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.. 1 PAGE 02/02 <br />11/02/2004 12:26 9166385611 CASCADEDRILLING ,-HUL �Jt1G� <br />y,r c%r .__iu iJ. .. J,4 W•J J J. V'•!WV JLl_VI♦ <br />,�g� , 4,J• 65B t oR A O <br />9;n Joaquin County Environmental Health Services, Unit IV Well Pormit Appliestion Supplalxmarit <br />,f-� DRESS' �Z �R& ��D0 � PERMIT �i�#: b 0 —8 2 <br />, 7+_s Ar <br />LICENSED CONTRACTORS DECLARATION L!D <br />i hereby affirm that I am licensed under the provislons of Chapter 9 (commencing With Section 1000) of Division <br />3 of the Business and Professions Code and my license is In full force and bffect. <br />#: <br />Expiration Date: % 2)1 —r) (0 <br />License <br />'- tractor: <br />Clete: ` �'� r <br />Title: •C` � 4 <br />Signature: / <br />Printed name: \�-24C22. <br />WORKERS' COMPENSATION DECLARATION <br />i hereby atfinn under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a cartifiCatw_ of consent to self -insure for workers' compensation, as provided for by <br />ti Section 37oo of the Labor Code, for the performanoe of the work for which this permit: is issuod. <br />1 have and will maintain workors' compensation insurance, as requlrad by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is Issued, My workers' compensation Insurance <br />carrier and policy numbers aro_; <br />Carper: .-- policy Number., �4 aL <br />_ I certify that in the performanan of the work for which thls 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 agrao that if I <br />should become subject to the workers' compensation pray s of ction 3700 of the Labor Code, I shall <br />forthW$ comply with those provision. <br />signature' <br />printed Name: <br />WARNING: rAILURIE TO SECUSE worinns' COMPENSATION COVERAGE iS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER To CRiMINAL PENALTIES AND CIVIL. FINES UP TO ONE HUNDRED TKOUSAND Do"RS <br />(stoo,000.), IN ADDITION 1.0 THE COST OF COMPENSATION, IN-M.REST, ATTOWNErS FEES, AND DAMAGES As <br />PROVIDED FOR IN S ON 6 OF THE LABOR 10OOE. <br />{signature W0447 gcensed authorized repmtentstive), <br />herabyauthorize (print <br />to sign thk Sart Joaquin County Wan Permit Appticailon on my behalf. I understand this autltorlzatlon is valid for <br />one (1) year and Is limfted to the work plAn dated on the front pope of this appiloation. <br />7-2000 I <br />