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48/17/02 MON 12:55 FAX 1 916 ^"1 0430 SECOR-SACRAMENTO 0 002 <br /> 06/17/2002 12:22 19166385 CASCADE DRILLING I,.. PAGE 02 <br /> uo: QZ ILON uy:u� raa 1 1116 051 uaau .}�r� yprk; Mlv <br /> e <br /> FD <br /> _ WINI <br /> sen Jeaquln County lnvktdt�rM�lldrMMh 10e>fr�11IMF Wep pe mR pppllceNen$uppb"tent <br /> JOB ADDFIEBS:,I �'J 5.����e/� S .�� f PERW SRO: <br /> Sf?c <br /> UCENSED CONTRACTORS DECLARATION WW <br /> I hamft aftirffl 9W I urn llosnead under Vo prvvtkm of Ghikpler 9(pprnfnen0in0 with SOOW 7000)at olmkm <br /> 3 of the eusness and profeeMom Codd send myNwr°o is in full*xw aft MIoCt <br /> LicPnso e: <br /> C57-71 7 510 E00kSlion pats:, 1 /31104--- <br /> Oats= <br /> 6/17/02 Contractor Cascade Drilling inc. <br /> Tine, Operations Manager <br /> $lgnatuns� <br /> Printed nomAk: <br /> Vera Chapman <br /> WORKERS'COMPENSATION DECLARAT" <br /> I hereby anirm unoer pmy of perjury oft d the totlew0q dedlatOW S' (CtifECK ALL THAT APPLY) <br /> t to <br /> 69N-Ineufe for wWkM,CMpgMgdan.0 pmvdW for by <br /> I have and will mawaeln a oorr =ft Ot OOftSen inti i9 1556106,Sectim 3700 of the tabor Code,for the psearmance of the work for which this Pe <br /> X labor Coda, <br /> 1 have srtd wiG rttair►taln worlt�tt'evrr4mustion IASUmnce,ss required by SOMIOn 3700 Ot tris <br /> for the pertottrt <br /> wWO vi the work for whlah thle PGFMR b Wued. My wotttera'tofttperteatlon lnaurancs <br /> Carrier and policy numbers are: <br /> Com�t <br /> Alaska National, pOS"Nmbar_ 02EpiS30531 <br /> I certiN that the parforrnene9 of the we*for rYldett rtni VWK iS 18SUed,I sit 1 not empbX W+y pdr�r"^ <br /> �y rttesmer so as to beoorrte nfbleot to go worked WMPeaeeti°n laws o1 Catlfemis,end agf+oe tltiat 01 <br /> should bsppme eublaCt to tris WOrkrers'oontpensakor+pr at Settlor 3y00 01 the Labor Code,I shell <br /> torthwilh comply with 0062 pravt3ions. <br /> I <br /> 6/17/02 <br /> Dew. Slpnpure: <br /> Pdrded Nene Vera G aptnan <br /> wutwraa;F�uw>ar To sZWM wor+�'WMPENS&T9W COVfHl IS a WKAWFU ,AND MALL SUBJWT <br /> AN O PIAT IER TO GRIM L PEl kL1rw9 AND 0M PM$fi U'x0 01sE 11uf�NED Tt10U6AltD OOt.�Al1s <br /> (Ot ao,ttao.),tN ON 0 TNe etiDdT OF CoMPFMMAIM STS ATYOR#M rs FWS,AMC)OAfIOAdEM AS <br /> PPOVIM0 FO ft 3700 OF TME LAe CObM. <br /> Sr►�wfe 011647 Ifioele"wEtfwdnw reprosentod". <br /> 1, 0 secor <br /> >,et*tryautfhoa�e <br /> �ee.a+e Elizabeth Grotenhuis <br /> to site tNa am 40WW41 CotffAtr <br /> Mtap PN00 APPOCOW on my beimlf. I wadermnit this duthoftnMon Is vdud for <br /> W*(f)year and in WFAW to tits Welk pian AMot►the hart) ot1MN ePpoeet;iert. <br /> I y17,?A001 MI <br /> I <br /> I <br /> I <br />