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Sari,lcaquin C.ounty Envirarsmpn5al Hewth Services, Unit Pis Well P rmit Application Supplement
<br /> I JOB DDRESa-_ 3_ G(a6 09(.•a. PERMI SR#., 00 320 (0LICENSED CONTRAC7ORS DECLARA ION (ICD)
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<br /> I heresyftirfr: tii<<t { ;iiren ed under the prc0s;o"S, YC-;I'fapterQ (cvrrmer ,`ing with Section 7000)of Divisiar
<br /> of the ELS;rieSS G110 Professions G nds and iry liCerrFin is in fijll T-]rf.c'. and e'fei t,
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<br /> License �: C57-717510
<br /> E•,i:ti,�ati,,, CGie: 1 /31 /04
<br /> pate - 6/26/02L,,,nt,.3ctor. Cascade Drilling, inc. i
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<br /> i Signature; -_ — _ _T— Title: Operations Manager
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<br /> Printed name: Vera C apman
<br /> WORKERS' COtiAPENSATM DECLARATION
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<br /> h8b r:, ;;n der pet-,. ity ryf paorj!,r;onta or f^Ilntdir'g de-darations: (UtIECK ALL THAT APPLY
<br /> i l ^•a'�"cr1C.V 'I trill.e1 iii t1 3wl1rT.i'icat,'of -,onsg �self-insure I I
<br /> -- w � nt t ;; i .sure ir�r'lvorksrs';compsnsation, as ;arovrded for t;�Y
<br /> I SeCbOr:2700 Of The Labs*r Code, for tt�e p G-mance of the.work for Urhi;;h this permit is issued.
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<br /> I f 71< a rTd �t `! mai t.2;ii�t :/WOM6i"S' :orr;pens�tio"� ir,sur�rl�'. as required bnt Section 37CO of the Labor Coda,
<br /> i },r the ;:e;10!—,Ia,lCe o`:'!e`Y 'irk f,ir which.this permit is issued. lk lv wor:(�rs'compensation insurance
<br /> icarr.-er and pu,jc;y nom1vers.are. i
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<br /> papier: Alaska National _ —^roi;.c Dumber: 02EWS30531
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<br /> Oer ffy that in the per f`, lapee of t~3 A'Crk Fos'v0ich this permit is is$uej I shall not employ any person ii;
<br /> ani ltsanr;wSO aS`G 3{;QfZYP Stl;:je i to ti,e Wo. lahs "of California, and agree that if i
<br /> shou;de._crr, . stel±jttt i3 the workFrs'clmp:?nsarior. pruv'.o ,_ of Sectidn 3700 of the Labor Carle, i s-alE
<br /> forthwitn �aomp!v wit,i lose p,r_,jr:sicrs.
<br /> i Date: 6/26/02
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<br /> Printed Name: Vera Chapman
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<br /> i WARNING., FAILURE TO SECURE'WORKERS'COMFEhEA.TiOhi COVERAGE ES i;INLAWFUL,AND SHAD SUBJECT
<br /> AN EMP-1-0YER TO CRIMINAL PFE HALT:E$AND. CIVIL FINE: LSP TO ONE HUNDRED THOUSAND DOLLARS
<br /> ($100,000.),IN ADDITION TO THE I-,O,'l•QF COMP51NSATION, IN TEREST,ATTORNEY'S FEES,AND DAMAGES AS f
<br /> PRC`;IEDED FOR IN SE r7;� 708 OF THE LABOR COLE.
<br /> (signature ofC-57 licensed authorized representative),
<br /> herebyau� rE:e tin# iatrat�._-- _DOrvgl`c-,S a.�- / +�-�'—/QyQ-h_ j
<br /> to sign this Sar.JLt in County Wall Permit AppFcatior�on my behalf. E unders4and this authorization Is valid for i
<br /> ones(1)year_yd is t'rtitW`C+tht work plata dated or the fr,•nt page ofChir appli4t►or?.
<br /> 5-17-2000 i ITii — -- j
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