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11114/2000 14 26 19166385611 CASCADE DRILLING INC PAGE 04 <br /> ` - DMZA 3d I N 1 a <br /> V <br /> IML M <br /> • �k1 i 7S= L - <br /> LICENSED CONTRACTORS DECLARATION (� <br /> I hSreby a"that I am kvnasd under the W0VW onti of ChWer 8(wmmenanp wdh 9eotlon 7000)of Dlvlelon <br /> 3 of the Duslneea and Prafesabn6 Go4e and my license Is In full fbncs and efieCt_ <br /> License# S~/ Q EypirStion Date <br /> Rabe d Celnirse t Cxj <br /> Signature• <br /> " ,fie• <br /> Printed name. O� G M G <br /> WORKERGr COMPENSATION OECLARATIOM <br /> I hereby affkrn under penalty of perjury one of the fallowing dsGbWkme: (CHECK ALL THAT APPLY) ' <br /> I have and w11 maintain a ewtttkatts of consent to OW4nwre for warkors'eampWWWdor,Ipnovitlad for by <br /> f Sacllon 37'00 of Ms Labor Cade,for the performance of the work for which INia permit is issues <br /> ]�.I haus and Wit moll taln workars'eompemation insurance„as required by Section 3700 of the Labor Code. <br /> T�for tte performance of the work far which thla permtt is a"d My wartcera'oornpQrWW*n insurarwe <br /> carrier and policy nun-hem ere: <br /> • Carrier aj a Q r d/1 Polley Nwnber. 6 4 EVI/S 3 o S 3 <br /> a <br /> I Certify that In the psrfarmanrs of the Work for whlch this permit W Issued, i shall not employ any person In <br /> any manner so as to become subject to the workers'cprnperisaMan lawn of Callfonlla,and ogres that IT I <br /> should become aubtect to the warkrs'compensation proves of Seatfon 9700 of the Labor Code,I shall <br /> fnrthwMh amplywlth those provisions <br /> Date �=13 T o ® Signature. <br /> Printed Name, r—o` G4- <br /> WARNIMGK FAILURE TO"CURB WORKERS'C0MPSMZA-n0M COWPAW to UMAWFUL.AND SHALL SUt3.1£CT <br /> AN EMPLOYff t To CRIMIXAL.?2M^LT11E6 AND CIIIIL F1NE9 UP To ONE HuNDRC9 THOvlit LARS <br /> (9100"0),IN ADDITION TO THE COST OF CONPENSATK*4 INTEREST ATTORNErS MRS,AND DAM^dWS AS <br /> PRCM0110 FOIL IN SECTION 3706 OF THE LABOR CODs, <br /> I,.- (elpneturn oyG87 licensed authorized nprwntethft), <br /> hereby autherhm(print nen:} <br /> to sign this San Joaquin Cocmty Weir Permit Application on my bebdf I understand this authartsanon w valid for <br /> one(1)year and la 1NnMW to the work plan stated ova the hent page of tltMa applImUm. <br /> ��>•-�000 r Ni <br /> i <br />