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JAM1819019166385611 CASCADE DRILLING INC PAGE 02 <br />CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provision; of Chapter 8 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is In full force and effect. <br />License #: (�, 5 / 7/-75—/b Explr2tlon Date: _ /— !sI DOS <br />Cate: 7-6 !� <br />Signature: __ �✓� <br />Printed name: <br />G 144, <br />�Cj , <br />TItIa. <br />QDci n � - a r7.Q r- <br />G ig/ a M a ?�J_ <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and wilt maintain a certificate of consent to self -Insure for workers' compensation, as provided for by <br />section 3700 of th6 Labor Code, for the performance of the work for which this permit Is Issued. <br />I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit Is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier:�1RSko� �IaftQnQ In Policy Number; 016-053o631 <br />WORKERS' COMPENSATION DECLARATION <br />I certify that in the performance of the work for which 111Is permit is issued, I sha!1 not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subjact to the workers' compensation pro ns of action 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 4pf — oJSignature: _ <br />Printed Name: MQ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SU3JECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), IN AOOITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />QL_0/ N1 a ,,,„„,,,,,+(C-57 licensed authorized representative), hereby <br />authorize /'1 GL * Y -A / rL C /i <br />to lion ti -it. Salt Joxgtrin County Wall Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is lim;t®d to tho work Flan dated on the front pago of this application. <br />S-17.2000 / MI <br />