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TTI SO_ • <br />II 7'0 62,7 <br />LICENSED CONTRACTORS DECLARATION (Lcp) <br />I hereby affirm that lam licensed urnler the provIslons of Chapter 9 (commencing with Section 7000) of Division <br />3 of Ina Elusiness and Professions Code end my license is in foii force and effect <br />License*: 71-,S--10 En3 inati on Dots: I-31-- <br /> <br />Data: ) 0 ° ContraCtor Cc 5 c ccic Dr c\ <br />Signature: Title: Op, r • <br />Printed name: e(7X C.Ac\ct <br />WORKERS' COMPENSATION DECLARAllON <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I heir, and will maintain a certificaste of consent to seff-insure for workers compensation, es provided for by <br />Section 3700 of the Labor Code, for the perforrnanc• of the work for *Itch trite permit is issued. <br />hews and will maintsln workers' compensation heursnoe, as required by Section 3700, of the Labor Code, <br />fur the performance of the work for which this permit Is issued. My workers' compensation Insurance <br />carrier and policy numbers are: <br />Carrier: \ N ad" 0 CIç l Policy Number: 0OG-V JS 3o_53/ <br />I car* that in the performance of the work for which this permit is issued, I ahem not employ any person In <br />any 'manner so as to becixne subject to the workers' compensation laws Of CiaiifOrnie, and agree that W I <br />Should become subject to the workers' compensation provIalE. • of Section 3700 of the Leber Code, I shall <br />forthwith comply with those pnovIsions. <br />Pats: 11 S-00 Signature: •• <br /> <br />Printed Name: e <br />WARNII(R FAILURE TO SECURE WORKERS' COMPENSATION COVERADE IS UNLAWFUL, AND SHALL 15111PJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND MIMS <br />(-$100,000.), IN ADDITION TO THE OOST OF COMPENSATION, INTEREST, ATTORNEY'S ram AND DAMAO/ES AS <br />PROVIDED FOR IN SECTION 3701 OF THE LABOR COPE. <br /> (signature orC-67 licensed amthertrurcl representative), <br />hereby authorize (pint name) <br />to ;In this tier Joaquin County Well Permit Application on my behalf. I understand this etittioritation le valid ter <br />one (1) you- end is limited to the work plan dated co me front page of this applIcatloe. <br />5.17-21300 I MI <br />11/1 5/2000 13:54 :_9166385611 <br />CASCADE DRILLING INC <br />PAGE 06 <br />mew