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12/11/2000 16: 21 530756164 ASE INC PAGE 01 <br /> 12/11/2000 16:52 1916631/1 CASCADE DRILLING a PAGE 04 <br /> 1,�/03129i,t0 15:22 63971561 40 ASE INC FAGE 09 <br /> Farm JbeyUW Cdrrnty Envlronmentai Health 8�ajs,Ul Itry Wslt Parmlt Appikation Oupplem nt_7 <br /> 40153, ADDRESS: /I qDD /V , FjArt_ � kp, pERMIT 9RM:� ` <br /> j LICEN3ED CONTRACTORS DECLARATION (4�C41 <br /> +hereby efdrm that I am licensed oncer ttw pamMons of Chapter g (dommenclrq with SaCIIOr 7000)of Livislon <br /> 3 or the Business and Professions Code and my I46n6e is 01 full force and effect <br /> License a: G.ar7 /7$- / 0—Expreaonosts• <br /> Dale CMlreosor Lr r� S C.tit A! � /J r— r_1.1�r N <br /> Bl0nature., Title: 0 2 �i�n��_qnay /" <br /> Printed mama: rCA, oy a <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby aKrm under penalty of psrj,�ry one of the fouaNng declarations, (CHECK ALL THAT APPLY) <br /> I have and will maintain a cedifkrelo of consent to seg-ktsurs for worNers'compormadon,as provided for by <br /> Section 3700 of the Labor Code. for the parformari of the wak toe which this permit is ieetxd. <br /> !✓I have and will meinte r,workers'Compensation inauranCo,ss required oy Sdt:.Ion 37W of the -sbor Cada. <br /> for the performance of the work for which tris permit is issued. My worksrW compansawn Ineurarleg <br /> carrier and policy nUmWs are. <br /> Carrier:X1.8 ��� n W Pdllay Number, DO 42' W O S 3 <br /> I certify thal in the performance of the waric for~this permit I$isevad I shall not empley env person in <br /> any manner so as to Decent*sub,*ct to that workers-compensation laws of C:sIdwrtla.and agree that If I <br /> Should become subject to the worker's'cornpenaakon W e 17%of the labor Code, I anal! <br /> forthwith comply with these proasrons, <br /> Oat*: jyZ / — 2_Signature: <br /> Print*d Name: )Xe.C.17i_____�..�.G.�!>'"� <br /> WARNINO:FAILURE TO SECURE WORKERS'COM136ANATION 09V911 iE la UNLAWFUL,AND 14ALL SUIL)ECT <br /> AN EMPLOYWt TO CRIMINAL PENALTIEa AND CIVIL 161hi UP To ONE HUMDFIEO THOUSAND DOLLARS <br /> ({'100,000.),IN ADDITION TO tNF COST OF COMPENSATION:INTEREST,ATTORNEY'S FIBS,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> t. __._ (C•61 licensed authorWd rePwsentobvt),hereby <br /> authoAae_ .-. f <br /> to sign this San Joaquin C*ullty Well Permit AppllCitlOn Ch my behalf. I understand this wthoWieden Is Valla for l <br /> one(1)year and I$Urnmed to the work plan dated on the front Page of this eppbootten. {f <br /> LI-1 lf-g0q(l I N1 <br />