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10 / 26 / 2001 10 : 50 19166385611 CASCADE DRILLING INC PAGE 02 <br /> 10 ; 2601 FRI 10 : 36 FIS 1 81-0 661 0480 SECOR - SACRAMENTO tojouz <br /> ' 01 / 19/ 2001 16 : 05 2994683433 FIFTH FLOOR PAGE 03 <br /> I Pill <br /> FJOSADDRESSP— AMP.0 <br /> ON <br /> an Joaquin County CnvironmentAl Health SurvW00, Unit N Wall tserralt AppIIc1rM n Supplement <br /> � PERMIT SOWe <br /> sser�t ,sv� ��f <br /> i LICENSED CONTRACTORS DECLARATION <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (OOMmancing with 3eetlon T000) at Dlvlslon <br /> 3 of the Business and Professions J Code and my license is in full force and effect2. <br /> License e: f/ S 1 L y /• EYplration Oats: / � v / � O C/� <br /> Date . V / (jprrtredor: cu r"f <br /> Title:, <br /> S{gna4+re: V <br /> Printed name: M <br /> WORKERS' COMPENSATION DECLARASION <br /> I hereby efarm under penalty of perlury one of the following d0claretlOI (CHECK ALL THAT APPLY) <br /> I ,have and will m llntain a cadit" ate of eensent 10 se&nsure for worlters' componsation, as provided for by <br /> Section 3700 of the Labor Code. for the performancs of the work for which this permit Is Issued . <br /> I have and veil maintain workers' compensation insufance. as required by Section 3700 of the Labor Code, <br /> for the performance of the warkfor wwh this permit is issued My workers' compensation insurance <br /> carrier annd. policy numbers are: J - <br /> II I K Q T/iI L Palcy NumberI F IA/SL3 IIIIIIIP <br /> Carrier. f <br /> I comfy that In the peRormanca of Te work for WMIGh III* permit is Issued, I shall not employ any person in <br /> any manner SO oe to became steJeet W the workers' eompensa n laws of GaiMomis, and e9rse that W 1 <br /> Should become subject to ttte workers' coii67C <br /> of Section 3700 of the Lobar Code, I shell <br /> forUtwlth cvmpiy with those provisions . <br /> Date : [o- Signature: ' <br /> printed Name ; <br /> WARNING: FAILURE TO SEOU D CIVIL COMPENSATION <br /> TO�GE a U OTT FUL6 AND SMALL 9�RflUBJECT <br /> AN EMPLOYER 70 CWMMAL _ <br /> PSROYIO® PORN LE ON 1706 OFT EFLASOit COOS�• WTET. AT70RNlY'9 P�>!. AND DAMAGES AS <br /> D/Y) Q/L (alonaturs elI licensed suNoAaed repnsentattve), <br /> Iw.by aumoAn (pant metre)_ ' <br /> J9 sign this San Joequln County Well frrmit Appllution OR my behalf. I understand this sulharlsetion Is valid for <br /> one (1 ) yearend 1s IlmRee w dr torte p <br /> Ian dated <br /> on the Itom page of Vue ePplloeaen. <br /> b'I7-�D00 / MINEW <br />