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11/15/2000 13: 54 191663E 1 CASCADE DRILLLr,WINC PAGE 06 <br /> Srz; i3 <br /> LICENSED CONTRACTORS DECLARATION (LM <br /> I hereby Stfsrn that I alit Bcenatld urWor the provisiorm of Chapter 9(commencing with Seaton 7000) of OMeltln <br /> 3 of the Elualness and Professiona Code and my license u In fWl form end effect. <br /> Litems ll- -71 --IS- 10 Expiration D/W: d <br /> Date: Conlractor r a S C' Q <br /> Sgndun: <br /> Tkl.• b� C I'`�1 a <br /> Printed - <br /> WORKERO, COMPENSATION OECLARAT)ON <br /> I hereby mnrm under penalty of pef)ury one of the following deciarat)ons: (CHECK ALL THAT APPLY) <br /> I <br /> _I have end wig malmain a pmurcete rel consent to selNnsure for worker'eompenueon,so provided for by <br /> Section 3700 of the Labor Code,ror the performsnce of the work for vAilch this permit to Issued. - <br /> ,1 hews and willmalnlaln workers'COmperenton insuranoe,as required by Saclon 3700,of this Labor Code, <br /> for the performa-,ce of ate work for which this pwmlt is Issue& My wwkera'compensation Insurance <br /> carrier/and policy nu mbers1 are: <br /> 1 ` . I 2 / <br /> Caviler•iT�6C kr1 Iv 0.T l0ill0 Policy Ntanber ()0 �WS C)-5-s <br /> I ca ify that In the performance of the work for which this permlt is ben00, I shal not employ any Person In <br /> any manner ao as to beocme suploct to the workw '0ompenoaton laws of CDlifanls,end agree that If i <br /> should become subject to IN workeri oompensatlon Rprovj*110^01 Suclion 370001 t»Labor Code, I*heli <br /> fonhwrth comply uNfh those provisions. <br /> Dab: Signature: <br /> Printed Name•. l F_y <br /> WARMINUt PAILUFM To SECURE WORKERS'COMPENSATION COVERAGF.Id UNLAWFUL,AND SMALL SI Ill <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (SI 00,000.l, IN ADDITION TO THE DOST OF COMPENSATION, INTEREST,ATTORNEY'*.FEES,AND DAINAOt?S At <br /> PROVIDED FOR IN SECTION 7706 OF THE LADOR CODE. <br /> t, IsIgnalury cMC-a7 llconaad avthonzed r.Pre.entetlw), <br /> hereby aut arWo(print rim) <br /> w sign this ten Jos*ln County Wal)Permit Application on my behalf. 1 understand this author"bon Is read fts <br /> one(1)yew and Is Iknttsd to Me work pian dead 00 the front Pegs of INA spPllaeon. <br /> 5.17-70001 L41 _— <br />