Laserfiche WebLink
12/10/2002 15: 16 19166385611 CASCADE DRILLING INC PAGE 02 <br /> 12/10/02 TUE 14:18 F!Lt 1 916 861 0430 SECOR-SACRAWN-r0 _ <br /> ®002 <br /> 04/14/2006 12:25 2694 x33 FIFTH FLWR �.. <br /> i U 41 Pam e4 <br /> 9dri'Jho;li�turat�.S�iY{fGRRtentalfliraMlt S�rylcas; <br /> Unit IV111I�{I PlsrmiF`A o T'r <br /> pAlit:atl ri: itr!!4!1t• <br /> 1 Ug <br /> LICENSED CONTRACTORS DECLARATION &SCQ) <br /> I hereby affirm that I ar-r licensed under the provisions of Chapter 9(commencing with Section 7/307)of Dlviaion <br /> 3 of file Business and Professions Coda and my IJcerse is in full force and effect. <br /> License �Jr - 71754 0 - Expiratlon Date: `_! ::-�- Off' - -- <br /> M": / Atractar: <br /> OJ�I ILN aA fz- In <br /> -- '� <br /> i Srgnaiure: Title: <br /> Printed name <br /> I <br /> WORKERS' COMPEM"T{ON DECLARATION <br /> hereby affirm under paratty of pariury ene of the following declarations: (CHECK ALL THAT APPLY <br /> t have and wi<I ma€Rtain I er <br /> o "cata of consent to l;alt-insure for workers'Compensation, as provided for by <br /> Section 3700 of the Labor Coda, for the pedbirmanze of the work for which :his permit is lenea. <br /> I have and wdl m�tsin workers'eonmpm-antlan inswarica,as required by Section 3780 of Me Labor Cade, <br /> for the performance of the work for which:hle permit is issued. My workers'Compensation 'Insurance <br /> carrier and policy numbers are: <br /> Carrier: P4, �k �L Poltay Number: <br /> _I certify that in the pertormance of the work for which this permit is issued. I %haN not employ any person in <br /> any manner so as to became subject to the workers'compensation Iowa of Cal fornia.and agree that If I <br /> should become subject to the workers'compar+setlorl pro 7n' n 3700 of the Labor Code.i anal! <br /> forthwith earrtply with these prcrOsions. <br /> Oate;� <br /> aa–10–OA 5191% tura: _ <br /> f <br /> Pr-Ntted Name- — <br /> WAimmG.FAILURE TO SECURE WORKERS'COMPENSATION CO1IEttArr:is UNLAY61FUL.AND SMALL BUSJECT � <br /> AN EMPLorER TO CMWNAL PENALTIES AND CIVIL FINES up To ONE MODRFD THOUSAND t?OLLARS <br /> jS100.EO FOR DITION TO-i-14E CO3T <br /> tt 37W OF T E�LABORc #Ap "SATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> l <br /> I, (C.s7,ucerwvd authrnsed rePrsaentadvel,haraby 4 <br /> :uIra c nn v 1 --- ._.., <br /> to fign this San Joaquin CouW Well PeRnKApplicatian on mY betrli. I u We+stand this aut1orisat4on is valid for I <br /> ane(11 year and is limited to the work piers dates/on the f22�e9e of 21I aaman. <br />