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11/1 /2000 13:54 191663k 1 CASCADE DRILLI ,INC PAGE <br /> logo <br /> l(n rant ,Sre: DG- <br /> ; - _, . <br /> b N� LICENSED CONTRACTORS DECLARATION (I= <br /> I hereby affirm that I am licensed ur10er tris pnwlslona of Chepmr 9(Commencing with Sod on 700D)of Ohdelon <br /> 3 at Ina Business and Professions Code and my license is in full forte and atfsct. <br /> Llcome 7t: [ I SIO Expiration D/W: I " a a— <br /> Date: Contractor Q S�Q 4 G D r , �n �•'C <br /> 6lgnaturs: Trds: <br /> Printed nems: ry'� CA <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby alYGm under panslty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I new and wll malmYhn a certificate ul cwwcnt to aefNnsun for workers'compensation, as provided for by <br /> Section 3700 of the Labor Cods,for the perfermsnce of the work for which this permit In IssUsd. <br /> 1 hove and wll maintain workers•aompermation ii.auranoe,as required by Section 3700,of file Labor Gods, <br /> for the ptafortnenra of Itte work for which this per nIt la Issued. Uy workors'oomponsatlon Insurance <br /> canis and policy numbers are: <br /> Carder:l a-& OL N ai 10.zg 1 Polley Number. O p EW s A o s3 <br /> _I rarity stat in the performance of"work for which this permit Is hued, I shah not employ any person in <br /> any merrier w as to became subject to the workers'compensation laws at California,end agree that S 1 <br /> should become subject to Ute workers'mmpensatlon p I of Section 37DO of the Labor Code, I shall <br /> forthwith comply roan those provisions_ . <br /> Data: 0 Signature: f_ <br /> Printed Name: k I R.`� �' <br /> WARNIMM FAILURE TV**CURE WORKERS'COMPENSATION COVERAOE IS UNLAWFUL,AND SMALL NUM.ECT <br /> AN EMPLOYER TOCRIMMAL PENALTlS AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ({100,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTOKNEY'6 FR®,AND OAM^004 AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, _lellinstum oFG4711oensad■uuwrtsed rspreaenbtive), <br /> hereby authorize(print neew) <br /> to sign this Sen.lowlLln County Well Par"Application on my behatt. I understand this aumorttiaaon is%ndd for <br /> one(1)year and Is Irrtted to the work pun dated op the front page of idea sPPllatloa <br /> I <br /> "!-2000 I M <br />