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1:/15/2000 13:54 19166381 CASCADE DRILLI INC PACE 05 <br /> LICENSED CONTRACTORS DECLARATION <br /> 3 ser Ieb Bt sinwend Prvfenaedssion4 moorode a a may ncor's.u fhapter 9r cu d ^7 encittill With seat;on 700C)of DMIlilon <br /> Llcsnse a` -7 1 -7 S 1 C) Expiration D/ase: / <br /> Date: D Contrector. r Iz Sc Q c G Dr , I I <br /> Slgndun/ Thle:d O C ��q — <br /> Printed name: Ck c,, rh <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of the following deoVratlons: (CHECK ALL THAT APPLY) <br /> _1 have and All mekneln a cMVr1cele of consent to selHnsure fa worker'Compensation,sa provided for by <br /> Sertton 3700 of the Labor Code,for the performance of the work forwhlch thle permit Is Isatad. <br /> 1 have and will maintain worker'compermebon inauranos, as requhsd by Socdon 3700,of fns Leber code, <br /> for the perform a of the work for which this permlt Is Issued. say workers'oomperteetlon Insurance <br /> carrier and policy numbers ars: <br /> Camsn It 1AS a N a4 i onq..L_Polley Number. QO EWS �o s-3� <br /> _1 ruNfy hat In the performance of the%000 0f wnlGt this pwrnk Is Wausd. I shat not employ any parse+ In <br /> any manner so ea to become subject to the workers'compensation laws of CaRwriis,and agree that S I <br /> should becoms subjad to die Aorkeri mmpensatlon RprovIslopaiat Section 37DO of the Labor Code,1 shall <br /> forthwith comply vim those provlgIons. . <br /> Dom: I I " I —�� Signatu r:_ <br /> Printed Name: � <br /> ! WARNINQ PAILURL To SKCVRE WORKERs'COMPENSATION COVeRAUF IS UNLAWFUL,AND SMALL SUSJE'CT <br /> AN EMPLOVER TO CNIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> [$100, DN 1I ADDITION <br /> ]Hof Oi 771E IT OF C <br /> OMP NS T�� INTEREST,ATTORMET'S.FEES,AND DAMAa fs AL <br /> PROVIOED FOR I <br /> 1 _,_I■lgn■lure cfC-e7 Moons"avvverlaw rprHsntstlw), <br /> herby authorise(print nano) - -to sign thle Sart lua*ln County wall Permit Application on my behalf. 1 understand this sutttorUV*n is rand to <br /> one(7)year and Is Ilmtted to Me work plan dead op th■front page of this applladoo. <br /> 'I 5.17-2rlw 1►tl <br />