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i 03/10/2004 10:40_ 19166305` .. CASCADE DRILLING PAGE 02 <br /> $/2$94-y 10:04 2094f .i AGE STOCKTON <br /> I <br /> San Joaquin County EnvlTowtrrtantal weafltll paMw"t pit IV it oll Perm Applleatort sappletsr�sr t -- <br /> Joe ADDRESS: ` PERMIT <br /> f ' <br /> LICENSED CONTRACTORS DECLARATION (l_,CD,) � <br /> I hereby arflrrn that I am IlCerssad odor the prosrinlons of C"llepter 9(aaantmenaing wFirra lila�ctlan 7000)M Qis is inn <br /> 3 of the 9uminM and Prafausiona God*and my Ilcense Is in U fo=arrd*VW, <br /> tlt�e'►.�*: �� � lxpirsriUari Dai � ,. <br /> Date, '"i _ 40Mcam <br /> treat4r. nSCAA0 ..I. — <br /> $i�eeate�es: TF!!*:2V Qnmn � <br /> I <br /> 8rleetsd naee�s: <br /> IAIORKII RV CRitlllPliifslZATION DECLARATION! <br /> I hereby afFArrn under penalty of pokiry ors*of the 1olbvwA9 declarations; (CHECK 0 WE) <br /> f have and will rr'mairftin a grrrtlkaatee of*Qrw*nT to*W-Inert for workers'oornponlisli0n,as provider o, <br /> by Section 3700 Qf the Faber Cocle,for the pedormprsse of Me vwrk br whloh ft-B hermit im inued. <br /> MMM and will nmintgln Workers'Compensation Insumnae,as required ray Sodtlon;1700 of"Labor C x e, <br /> for the perfortnamn of itt*work fid UA1ich this permit 1$ieauad, My workers'cum pinsatlon insurance <br /> earner and policy numbers <br /> t:srriaer: iiinPa w M>,mbvr;fir,, �b NIs , ) _ <br /> 1 certify that In the pgrrvrmar oft ,@ Nork for Whlph"a permll Ig isogon,1 shall nat employ any Dere-I ri . <br /> any manner so as tv become subject to ttsrp wafters'compensation Awe of Callft,�rr:i*,arta'some that if I <br /> I 6"QUIC Decorne Subject to the vrorl�ers'conmpenaatlOn won$ Seo0on 3700 of the I*bar Coda 1 t ru 1l1 i <br /> t forthwith comply Mth those provisions. <br /> mals. $Igeewrtsera: .Y. <br /> Pllntea!IIRA1q. <br /> WAa'tNJNQ:rAILURI!TO SacVRg W9gKaji$'COMPl8i+13tATICN COVERAGE is UNLPAWFVI.,AND SMALL SUEW E(T <br /> AN 11114PLOYER TO CRtraawAL 109N ALTIi6$APO anvil.F114ES UP TO ONO HUNDA110 THOWAND VOLLARS i <br /> #11140a.004.),IN ADDITmw To t"S CWT OF 90MPCtQATION,INTARaaT.ATTORHINV''S F e F!9,AND DAMAQ23 a:; <br /> PROVID110 FOR IN 3 ECTIAN 3706 OF THE LAWN CODE <br /> A117H T N FOR THAN C-67 SIGNING PERMIT A13PLICATION <br /> �'�'�' [srga9#t4ir'6 vfG+dF I1dlBrrarAlt e11;Ra+risaed aepnaasntal Iva}, <br /> ksy auth*dnra(peri 0M*J <br /> to sign lh13 than Jasarlrein County Wall Ramal lAppdicolJon on my b4of, I anderut nil thea alrdruriasUan is valid,or <br /> OM(1)year acrd Ira If hod to the work 040 41ftW ado ft ftt"page of nein aepptlaw,a#Ian, j <br /> 4Y/Mi <br />