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11/15/2@00 13:54 19166385,', CASCADE DRILLII,..'HC PAGE 06 <br /> LICENSED CONTRACTORS DECLARATION (E_CD5 <br /> I hamtry affsm that I am hconaed unaor the Psora of Chapter 9(Cammendrig'M Boaon 7oo0)of Division <br /> 3 of the 5uainess and Professions Code and my license is In fall form and effect. <br /> Ucsrse S: 7 5 1 -7 1 0 Expinebon Deis: — // d <br /> Date: <br /> Contractor 1^ rd r C c4 `J c <br /> Title: <br /> Slgnatars: - --- <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm urMer panelty of perjury one of the following deciaradana: (CHECK ALL THAT APPLY) <br /> _I have and will melntwln a certificate 11 wnsoM to seK4nsure for workers'eampenPetlon.r provided for by <br /> Section 3700 of the labor Code,for the Pv'rohnsnw of the work for which this Permit is Iwtad. <br /> �.l hee id witn �orsscode, <br /> fr the Ferfvraxe of ae wok for which pemtIissued. My wukera oornp r%aabInsurance <br /> carrier and policy nurnbera are: 1 <br /> Carrier.4 "lac lCa N ajionq..L.Polley w ariber. DOEWS --:� C)-5 f <br /> _1 cnNfy that in the Performance of the work W which thk Permit Is bsued, 1 Shat not WnPtoy any Person In <br /> any manner so es to become subject to the workers'compensation laws of California,and agree that If <br /> Should became subject to the workeri compensation provlsl of Section 3700 of the Labor Code, <br /> forlthwith comply vAth thou provisions. . <br /> Dab: I 1 c> —0 D 81gnstum:_ (,, <br /> Printed Nems:� vr- C' ` <br /> WARMINM PAILURL TO SECURE WORKERS'COMPENSATION COMRADE IS UNLAWFUL,AND SMALL SUISJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINEa UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PFOR I <br /> (SIOCAOO.), IN <br /> ADDITION Da O THE <br /> E Oi THE LABOR OMP TTK)NSAINTEREST,ATTORNEY'S.MRS.AND DAMAGES AS <br /> i Islanstum OC-e7 licensed euvwmA sal repmeentetive), <br /> hereby authorise(print narne) -to sign ihle Sen desWln Courter W NI Permit Application on my behalf. 1 ultdsrstand this IRIMOrtisbon is valid Tar <br /> ons(1)yearend is limited to die work Plan dated uP the front page a'tNa eppltalJoe. <br />