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11/1 5 /2 000 13:54 19156385611 CASCADE DRILLING INC PAGE PE <br />LICENSED CONTRACTORS DECLARATION (Lcp) <br />I hereby elan the', I ari Bconsed Mier the prcrAdone of Chapter 9 (commencing with Scotian 7000) of Division <br />3 or the Business and Plut_lazionts Code and my licens• is in full for end effect. <br />License*: 7 I —7 S.- 1 0 Expiration Date: j — 3 / — 0 '3 <br />Date: 0 (,),, cont, rict_S-C c1C Dr; Ili cN n <br />Signature: Title: p cA M r • g--- <br />e Ck_c4 r•r-Y - CA IN-- <br />WORKERS' COMPENSATION DECLARATION <br />hereby erfirm wider penalty of perjury one of the following decliaretlana: (CHECK ALL THAT APPLY) <br />I heire end will maintain a certificate ol ooneent to setf-insure for workers' compensation, es provided for by <br />Section 37110 of the Labor Code, for the p erforrncric• of the work for which Vila pemill Is Issued, <br />hew, rand will maintsin workers compensation korurence, es required by Section 3700 of the Labor Code, <br />for the per-forme-ice of the work for which this permit Is issued. My workers' compensation Insurance <br />carrier and policy numbers ans: <br />ft- 10,_&Y,u CAdOfl9 Policy Number:, F-\,\JS 3 053 <br />I curly that iv, the pertomience of the work for whIc:n this permit Is Wiled, I end riot employ any person In <br />any manner so to to become subject to the woriters' compensation taws of California, and agree that If I <br />should become subject to the workers' compensation provIsl of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Oats: S."- —0 0 Signature: <br /> <br />Printed Name: e <br />WARNINQ PAJLUNE TO SECURE WORKERS' COMPENSATION tXIVERACIE IS UNLAWFUL, AND SHALL 51.11BJECT <br />AN ENFLOYER TO CRIMINAL PENALTIES AND CIVIL FlitEls UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE CCr9T OF COMPEINSATSON, INTEREST, ATTORNEY'S FEU, AND DAMAGES AO <br />PROVIDED FOR IN SECTK)N 37OS OF THE LABOR CODE <br /> ielanature cfC-57 licensed authorized representative), <br />hereby authorize (print risme) <br />to In thIs 5en Joaquin County Well Permit Application on my behalf. I understand this Nithortaatien Is valid for <br />one (1) your and Is limited to the work plan dated .00 the front Page cri this applicatica• <br />I 5-174000 / Mi <br />Printed name: <br />°Biel 1