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03/01/2002 13: 39 19166385611 CASCADE DRILLING INC PAGE 02 <br /> MAR-01-02 11:U FrairURS SART + • T 18S P.02/02 Job 3A0 <br /> ban Joaquln County Environmental Health 30mleea,Unit N W*II par-i App <br /> IkatWn Supplement <br /> J013 ADDRESS: Ifir W PERMrr SRO: <br /> Tea cAt I CA <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I nm.Ii=sad under the proaslaha of Chapter 9 (Gommencinp with Section 7000)of Division <br /> 3 of the Business And Ph sssions Code and my license is in full force and affect. <br /> Expiration Bate: January 31 , 2004 <br /> Cascade Drilling, Inc. <br /> Dodo: 3/01 /02 <br /> onuactor <br /> 8lartature: �, Title: OP�ra,tion8 2'lanaQeY <br /> Printed name: Vera Chapman <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pcnolty of perjure/one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a oartiflosto of consent to salt-Insurs for workers'ocmpenssilon,AS proWded for by <br /> Section 3700 of the Labor Code,for the Performance of the work for which this per"Is Issued. <br /> X I have anti atilt maintain workers'compensation Inaurenoe. a$ required by Section 3700 of the Labor Code. <br /> -T for the performance of the work for which this permk Is Issued. My worker.'compenaadon Insurance <br /> carrier and policy numbers We: <br /> Alaska National Policy Number: <br /> OlEWS30531 <br /> Carrier: -- <br /> I certify that in the performance of the work for which this permit is issued, I onell not employ any person In <br /> any manner so as to beecrtle subject to the workers' compansatlon laws of 7 Ifo a��Code. I shell <br /> should become 6,lbjxl to Nle workers'compensation provi of <br /> forthwith comply-A those provisions. <br /> Date: 3/01 /02 Signature: <br /> Printed Nam*: Vera Chapm <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND$KALL SUSJECT <br /> AN LMPLOyER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONC MUNpRob THOUSAND POLLARG <br /> i .IN CIN ION TO HE OAF THE COMLABOPENSATION.INTEREST.ATTORNEWS FEES,AND DAMAO"AS <br /> PROVIDED OR <br /> t Vera Chapman (C•a711osnsed authorized reprswrdtave),herby <br /> authorite U R S <br /> au <br /> this Son Joaquin County Well permit Application on my behalf. 1 v,.derstand this author:lzsaon Is valid Tor <br /> nne(t)yser and Is Ilmlled to the work plan dated on the front peps of this application. <br /> 6.17•]000I MI <br /> 4k <br />