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09/09/2003 09:44 1916638F^ 1 CASCADE DRILLING 'C <br />09/09/2003 09:56 20946. 8 AGE STOCKTON 1ah/ .. _..... ,. . <br />3 <br />sari Joaquin <br />JOB AADREM 9S aj �/ �GtG_y-rC f} <br />rY unser <br />PAGE 02 <br />P 4GE.,, 03/03 <br />PERMIT SRO -003 5Z2-6_ <br />LICENSED CONTRACTORS DECLARATION -QM <br />I hereby affirm that 1 am licensed under the provisions of Chapter V (cpmmHrangwith liedion 7Oo0) of CWL. ,IOn <br />3 of Cie 0usinesa and ProteWoniear <br />s Code and my so it it fell force and effect <br />License # - 7 113 <br />Date: <br />Signature: <br />Printed "Mo. <br />Deft; <br />WORKERS' COMPENSATION DECLJIRATION <br />I hereby affkrr under remit of ParIIsY one of the blowing declarations: (CHECK 010E) <br />I nave and unit mainta n a ceftlfiosta of Cement to aatf4mure far wvrkae' tornponssdon, ere provided for <br />by Seo6on 3700 of the Labor Coda. for the perfbrmenes of the work for which this p lmiit Is issued. <br />p_ I have rid will maimain workers' Compensation instawca, as raquired by Section 3700 of the Labor Cod it. <br />for the Performance of the worts far which this permit is issued. My workers' tdrnporaeion insurance <br />Carrier ord policy numbers are: <br />tAMW; .I�f1Q l - POReyNumber: <br />I cartty that in the "AmmahCS of the Walt for which this permit Is issued. 1 shall not employ any person i i <br />any mariner so as to became "Oct to the workers' compensation laws of CalNomin„ and agree thei.T I <br />should became subkrot to the workers' bomperisatibn pmvi a of Sect on 9700 of tie Labor Code, I she I <br />fw.hwhh fcomply with Stage prWASIoM: <br />Data: S11111"apnv: <br />Printed Name: <br />WARNING: E MLFAILURE tie TO <br />PSE ru.� AANND CML NES UP TOOVlON COPED Ti wsgAM spa LARS ue I r <br />(31 eQOOO IN ADDITION TO TNF COST OF COMPENSATION, WMREST, ATTORNEY'S tFE11, ASO DAMAO6a AS <br />PROV10® FOR IN 3ECNON 37D/ OF THE LABOR COt36. <br />AUTHORIZATION FOR.0 THANC.8 ING PERMIT APPLICATION <br />�W licensed wMaAweranreer+bWa. <br />bag" 8"110113a (mint "epee) . D -r1 Y -t 0k, ,/1 <br />to siafr this Sari Joequtn Cpemy Well fennel AWFUM" en my beltaH. I undertow Yue wesrtsatlon is valid for , <br />mme (+) y*w wed 1e 114 Of m pre won# baa domed on the fr we page of thle appileatian. <br />i e�as� r sY <br />r <br />I <br />