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10/09/2002 14: 42 191663P"11 CASCADE DRILLING INC PAGE 92 <br /> 1k3/69J2{ 132 t :G$ c094 1$ AGE STDCXTCIN FAGS 02iBi <br /> I <br /> � erl.ioaquln Countg F.nvironmo t Health Dep�rtm� rtkunit IVW6111 Werrrdt Apitllt1Qsg Sup�it3rrfe�4 <br /> I <br /> r PERMIT SRS: _ II <br /> JOB ADDRESS: � <br /> LICENSF—D CONTRACTORS DECLARATION (.LC0) <br /> j I hereby affirm that I am ilcensad under the P'gviriorts of ChePlOr g(rr mMencing wittl SeCtiori 7000)of Di•4'sian <br /> j 3 of the t3usineS9 and i'ro`ossions Code and ray llcanso is in fLdj forts anti effect. G <br /> r -•_.__ �__ xpiratiU-�Cab. J�'__. .M, <br /> r)s te: f C�+ _-- rztrdCtOr <br /> Tido: <br /> _� Sl�nature� <br /> - F Printed name; <br /> WORKERS' C0MpF_NSATfatd DECLARATION <br /> !hereby affirm urtd@r penalty of Perjury onR of the`c�;lowing c eciaratiorts; (CRECK ONr <br /> and gill main!Sin a.certlftcate of Consent to self-in WO for vrorkars'corripensalloni az orol dp for I <br /> Qy section 3704 Qt the Lab+sr Cada, for tie pcarformance of the work#or which this parmit la i0cue - <br /> X I have anti will maintain workers'compensatior' Insurance, as required by Sectbn:700 V, the Labof 0010, <br /> i #or the performance cif the wofk for which O!s permit is issued. My workers'carnpenbec-on lns,jrarce i <br /> i C.",rriof and policy nurrsbtar$ pre' <br /> Policy Number:—W&IA 2?.�� <br /> I certfry that in V16-PeQI-m8nCQ of:he wort(for which this permit�s is Hd, I shall not t;rnpIQY any Person i:' <br /> i any manner so as+to becoMO$0bjecl to the workers'ccmponsatio X13 Of California(, and spree that if I <br /> f should becoms s0jset to the wvrl<ers'cor►per1Satlors pr inion Section 3700 at the Labor L'o6o, i snail <br /> provisions. <br /> � forlt'Iwttf�comply with t}lo6c+�' , <br /> �P pate; L O-5`" __Signa�4uto: - <br /> 'nt d Ida rrm: <br /> I <br /> PrI c J <br /> wAttfV NG, FAILURE TO %r__(;uR:WORKIRRS'col INFENSATION COVERAGE IS UNLAWFUL,A14D SHALL SUBJECT i <br /> lr pLf7YEFt TO CRIMINAL-f IFNALTIES AND CIVET. -INES UP TD ONS#IUI�R�iED TFtOt�AI�D I?C?lLffRS <br /> (%100,000.) fQA N�ECN Y,o �tE COST®P VH¢1COMPt CODE- <br /> AUT <br /> INTI!REST.A TORNE!"S FEES,Al"D DAMA GrES AS <br /> PROVID <br /> THAN C-57 SIGNIING PERMIT AITPLICATION <br /> � A�,bT t 'I`iON EAI � f <br /> _.^(Fignaturo otC•57 Ilcon>ted authoris*d r�sprem,0111Wvub <br /> herebyauthorlxe(p 'nt name�� 1�_fA <br /> to fior,Shis&an j4fA;awiA Ca*tnty vyoq Permit Appflemlon on my bsh�alf. I undoretend this eutfgartWIDn 10 VRlil fpr <br /> I <br /> anm(i)tsar r,d'e tisrtittd to tht+work plan dat*d on tho front R of tftft�001catoon. <br /> B-3t}-A2/PAI ._,--..�.....----'..� ---• - �--...�..____ �.M—� <br /> I <br />