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OS/08/2006 15:48 91663851— CASCADEDRILLING �� PAGE 1 t� <br /> 11Nr,. JV. LVVV T.VAI IndLCu vav6l1v I I V11411C[I L I rya. DOI4 r, 1 <br /> San JOargUtn Gourrty ErrWrotrmentol Wealth Department Unit IV Well Permit Appliva#icn Suppled NA <br /> [SA s—t) <br /> JOB ADDRESS;_ 1 U. PERMIT SR#: D O Z.Z <br /> LICENSED CONTRACTORS DECLARA►110N LCD <br /> I her*W ati-irm tit I am Ike sed under the pnMslans of Cher 0(ew nencing vft Section 7000)of OMMon <br /> 3 of to Busirraas&W Pr %swfarea Gods and my Iftnss Is In Bill 10M and effect. <br /> Ltcenae�lr _'"' 1 . f 0 <br /> !ir <br /> .� <br /> 04aig <br /> signet u rte- //^^ �T <br /> Gft, <br /> Printed name: Y 'S LA,—t' t1rr e <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby afti m urs penskyy Of psrW orae of the following dols'i iow. (CHECK ONE) <br /> 1 ha ft sued wol rnairttaln a Off"Mte of corwmnt to deft inmm f0r workers'fin.as MMW@d for <br /> by Sadfon 3700 of the Labor Code*for Ow perfvrmanoe of tfra work for wllfah this permit Is issued. <br /> I have dna loin malrltoln workers'campormuon il,muranoe:,as required by Section 3700 of the Lobar Code, <br /> firer the perlbrmanos of the work for which fts pem*0.bwW My ulrorlaera'camperlsa#ian IneuAana+ <br /> WM*r ane policy rpofters are: <br /> t.+arl ae: Ot 0 YL 04 poncy mumbsr. ��-IJIJ <br /> I ON*0*in the partioflne M of the work for which thta permed li ieeuad,I&hail net employ wy p9mm in , <br /> WW Mmruw so as to becomE VAOd to the w+nrkers,caMpefEoltddrr W"of CalltarNq,snq agme thea j I <br /> ftdd become avbjed to the wwkow owpenaadon prowsk m of 8 3M of the Labor Code,l#W1 <br /> fo twmh comply with those proyWom, <br /> txpiretiran Date: "[ signature: <br /> • r <br /> Printed Name: <br /> WAl Jo4b;FAILURE TO$Mit WOWRet CoMpMSATON COV'ERAM IS tMLAWpUt.ANO SHALL sUR&NOT <br /> AN WAKOM To OWMN&IiEIrJ LABS AND CIVIL P14CO UP TO GW6 PAHO TFtO�WLLARS <br /> RIOC,OK1 IN ALMMOM TO THE opgT OP COMPI5NIA'i'fDNt INTMM,ATraftl rs IMS,AND DAMMIN As <br /> PRMDW FAR IN IKTIGN 37M OF n fs ullOM CWL <br /> AU7"HAR T10IV THAN C-S7 SIGNING PERMIT AILICA'I`i0N <br /> 4 (aignatw4 a11C-sr sodnsed augrortxsd�eeen4aft+rey, <br /> hereby■usarese(Print Hama <br /> to sign this art dosgeeln Cc"WAN P@neelt Appliusuon an mvy bftlf. I andenwWw thio aulharf ton im valid for <br /> ora(1)year aced is peeked ea See walk plan dated on I*ftwA page of thin*W aation. <br /> 1 <br /> >�T9-Gd•C01 <br />