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02/27/2002 13:16 6027280"-9 BLAES PAGE 02 <br /> DRILL. INC PAW 02 <br /> 5�E1l:Jai>tllpUiFrt' uo ► 1tat11'IA IIi►i11� >} Ilf <br /> _ *MVW tnit V WAH ParM - p -cat-gg . <br /> apla <br /> nNnt .. <br /> job,tA) g 44 !fort wilaon. Way PERMIT slR t. <br /> . . <br /> .I .. h.,. .. .. <br /> I <br /> I i <br /> LICENSED CONTRACTORS DECLARATION <br /> i <br /> I hereby&ff+rm tot i am fic"Od,order the provlslw9 Of Ghspter 9(Commfineing with Sectlar, 70M)of Dive of <br /> 3 of the Business and Professions Code w-o my 4cenm is in fill force anC effect <br /> t t.ioensetk.J_C57-717510 Expimt+on Dates 1 /31 /04 <br /> ' Gate _ `2/1 1/07 contractor- CAscada Drilling, Inc. <br /> Stpnature ��Tlela• Operations Manager <br /> Printed name! Vera opmarl -� <br /> WORKERS' COMPENSATION 0ECLARAT10M <br /> I h6i affirm under 06fi ttty of Penury we or the following declarations. (CMCK ALL THAT APPLII) <br /> _1 'Mew di Will Maintain a certft. ate of consent to tcelf-Insura for workers'oornpensatior,as pr'ovideo for by <br /> Section 3700 V tt* -40or Coact, for lye Performsrrce of the Work for whICM this perm4t is issuod <br /> X i -taw arc will maintain worker$,oet-tprUialiprl In l <br /> P ourence. Ma requlrad by Secoon 3700 of the Labor Code l <br /> . -.for the pefro"no"Ce Of rip Work for which Vile permit Is Issued. My wOrttefs"oompenaallon insurance I <br /> carrier and policy r,urrmbers are: <br /> C�atri«; Alaska National Zeta , PolicVNurnbsr. OlEWS30531 <br /> I certify that in the performianea of the work fOr which this perm It is issued, I sha:l not ernpioy any person,n <br /> I <br /> any manner loo as to becom a subject to the workers'Cernotersollion caws Of C+litomia,and agree that it I I <br /> iiii beoorre ttuuisct io the warkdrs,carnpt►risatron prov,eiana of Seadon 3700 of rhe 4 aY er Coda. I stisrlll .I <br /> fore with comply with those provi"ns <br /> OWN: 2/11 /02 _ Siynatufs: <br /> _w. <br /> Printed Name, vera G pman <br /> WAMINO: FAILi TO BrCURE WCIRKER& COMPEMUTION COVERAGE 12 UN"WPUL.ANO SMALL eUMiJEC? <br /> AN KIMPLOTER TC CRIMINAL FMthAL71aS AND CIVIL FINE$UP TO ONE NUNORED THOUSAND DOLLARS <br /> (61d0.tlDD.).IN A001-10N TO THE COST Us COMPF1113ATION,MTERE37,ATTplitijr 's r-9M3, Aye b"AOES A9 <br /> OR!OVIDEO FOR iN 2ECTION 3706 OF THE LABOR COlom <br /> Vera Chapman <br /> wuthadAWd�op,rsentytiv�y, h�r�bY <br /> autAOrt>;e� Blaes Environmental <br /> to sign th:o SSr dpii in County Wet Perntit APINICAW'n on my beh&K i understand this ultnOrizatlor lr`Valid:or <br /> one(1)yser end Is I1m!taci to the wank plan dataa On int hunt Dago of this•ppIWM;on. <br />