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08/28,`2002 16:48 191_-6385611 CASCADE DRILLING INC PAGE 02 <br /> 08.'28/20$2 12,08 $0272""►38 8',.,AES PAGE 03 <br /> *1-ftpw Aw- <br /> zf�q f - C:9--�/ W` ` CC <br /> t4 ` <br /> San Jo"uln County Envlr Rtental Wealth Department Unit IV Wap Pon"R Application lupplio ,ant <br /> JOd ADVRlS8: l!/ PERMIT i9RE: <br /> Q4�LICENSEU GOUI-Tftg1+fO43 DECLARATION (LQ <br /> i <br /> I hereby olMlrm that 1 am licensed under the provisions of Chapter 9(oorrrnencing with Soctbn 7000)of Division <br /> 3 of tfre Susinees and Professoo is Code and my itcense is in tuff force and effect. ! �/ <br /> Litems 0, G 5 r7 '7/ 7 S/ a Expiration Date: <br /> Dole: g v1-.. Gontractvr. C a ;C R dc- D i- <br /> Signature: Tate -01e,-01e,C- r it el a t <br /> &a f''I <br /> PrtMed Aar"*:.. :. x R 10 1-4 OZ-11- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby o irm under penalty of peyury one of the foiivwinq deciarstiors: (CHECK ALL TWAT APPLY) <br /> I have and will maintain a certMcate of consent to self-insure for workers' compensation, wis provtdad for by <br /> Section 3700 of the Lobor Co",for the aprformanc*M the work kir which this permit is issued. <br /> �',l naw"Wil maintain nmj.a.lc*.as jerjji;iaG by 3ectrlon 3700 of the labor Code. <br /> Ttx Ale perlvrmance or the w9m Tor which this pormit is issued. My Workers'QvmponsaGon iinsuranOe <br /> Barrier and policy numbere are: 1 � ' <br /> Carrier: #l a S c, /ar r�i l 7 d/i Policy a c�—E Vy Number: 5.3a�713 <br /> I certly that in the performance of the work for which this permit is issued, I$hail not ernpioy any oerson in <br /> any mr anner so as to become subject to the workers'compenilobon laws of California,and egos ftt If I <br /> •Mould become subject to the workers' oompensetlon provisions of tion 3708 of the tabor Code, I shaft <br /> forthwith comply with those provisions. <br /> Dew: ' R'' Sionature: __-- <br /> Printed Name: L�,! �� C T1Gp rn Cz <br /> WARNING: FAILURE TO SECURE WORKiERS'COMPENdATION COVERAOR 14 UNLAWFUL,AND SHALL SUBJECT <br /> All EMPLOYER TO CRIMINAL PENALTIES AND CIVIL IFINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1f1t10,000.) IN ADDITION TO THE COST Of COMPENSATION,INTEREST,ArORNZro font,AND DAMA929 AS <br /> ►ROVIDWZ* j::C37014 Of THE LABOR CODE.1. (alpnstufe WC-b7 lice med authertaedherew aulherlse( l — <br /> I to sign this Sen Joaquin County Well Permit Appilcatlon an my behalf. 1 urxderetand this su"10ft tion to valid for <br /> one(1)year and Is Ihnited to the wort pJen dated an the front Page of this application. <br /> 1:"6021111111111 <br />