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10/07/2003 13:00 19166385611 CASCADE DRILLING INC PAGE 02 <br /> 10/07/200.3 13:01 916951`' Au Jam• -, <br /> San Joaquin County l-nvironmontal Health 5r" Ices,Unit IV W91I Perwtlt APOIC altlon Supplement <br /> J013 ADDRESS: x"16 S Grarr+ L,No— J-xcq. GA PERMIT SR#f: <br /> LICENSED CONTRACTORS DCCLARATION <br /> I hereby srfirM that I am 11cansed under the provisions of Chapter 9(commencing with Suction 1040)9101vision <br /> 3 of the Susirwse and Professions Cede and my license is In full force and offew. <br /> trcanse Ii: G5"T— 11"T, lc� _ _ Expiration Date: 1 0 <br /> Date,• 12i2lT a3 Contractor: dS e,-4 I I;rti <br /> Signature; Tlft <br /> Printed 04ttl0: <br /> WORKSAW COMPENSATION DECLARATION <br /> I h0eby affirm under pervilty of perjury one of the following declarations: (01.1130K ALL THAT APPLY) <br /> I have and elft maintain a cerNfkate of consent to see-insure for workers'compene don,as provided for by <br /> SeoWn 3700 of the I-Oor Code,ldr file performance of the work for which this permit Is Issued. <br /> I have and will maintain workers'componsaWn Insurance, as required by Suction 3700 of the Labor Code, <br /> for the perform>anoe of the work for which this permit is issued. My wvrkerV compensation insurance <br /> oarrier and�prollicy numbers are: �. <br /> Carrier: �, ,� % Polloy Number: (Z)3 C-&) � ! <br /> 1 certify that In the poi'formamce of tilt work for which this pgrnlit is 13$U*d, 111hall not employ any person in <br /> any manner so as to b000me subject to the workers'oomparisatlon laws of California,and agree that If I <br /> should become subject to tho workers'compensation ovfsiona f Seotlon 370Q of the Labor Code, I shell <br /> forB>fuffh comply with those prcvlalona. <br /> Petr. 1 d" 81�rtature: <br /> Pfjntsd Marc: <br /> WARNING! PAILURtE To BECURE WORKERS'compamsAmoN Covamal is UNLAWPUL.AND 61144"SUBJECT <br /> AN ZWL*VLA To CltlWNAL.PBNA6T729 AND CIVIL FINES UP TO CNE HUNDROD TPNoUS"D DOU ARS <br /> (;1ott,oGC.1,IN ADDITION o THE OF CompliNBAtION,INTf aLrST,AY'h ANldv'S fes,AND DAfNAQES AS <br /> PROVIOCD FOR IN 3 If OF"is LAt30A QODE. <br /> I� (signature ofQ41 liwnsed whodad NpressntaNvs), <br /> frawabywuthorixe(print nsr►►s) �Gi t' <br /> to sign this Sea.roaquin County Wall:Pennit Applleollon on my bahsff. I untpratarid this suMorisrrtlod is'vtlf#d for <br /> our(1)year and le IIm ted to thhe work plan dated an lila trout pigs Of this NPPNvatlon. <br /> d�1T�000/KI <br />