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J4 1Jl0000Jb11 UAbUADE DRILLINGINC 00/0612003 05:52 916861011ju ZQ� PAGE e3 J00 ADDRESS: Sa PERMIT SRN. 6035 o� CA LICENSED CONTRACTORS DECLARATION I hereby affirrn that I am licensed under the prov;sfons of Chapter 9 (commencing with Section'tOM of Division 3 of the Bualrwvs and Prof*s4lans Code and my Hcanse I9 in full force and Affect. License e: 7 - 1-7 .,`�' l Expiration Date: 1 - 0,A)! -0j Dato: 6- - Contractor: Signature: u Title: Printed name: I hereby affirm under penalty of perjury one of the following doQlaretivnto: (CHECK ALL THAT APPLY) _r 1 have and will maintain a eertlicats of consent to self -Insure for workers' oompte'► aWn, as provided for by Section 3700 of the Labor Godo, for the performance of the work for which this permit Is iasued. I have and will maintain workers' oornpensation Insursnce, as required by Seotion 3700 of the Labor Code, for the performance of me work for which this permit is issued, My workers' compensation insurance carrier and policy numbers are: Carrier: _'o%\Nc.-�kN � -C)ID I Policy Numtmr: I certify that in line performance of the warts for which tints permit is issued. 19ha!I not employ wiy person in any manner ac As to bgWme subject to the vmrkera' c nsation IMNS of CalHomla, wW agree that 91 should becorn• subject to the workers' oompensaNn erre of loll 3700 of the Labor Code, 1 shall forthwith comply with those provisions. f7ate: _-_(,Q-<�k Signature: Printed Name: WARMNO. FAILURE TO SECURE WOAKERS' COMPENSATION COVERAGH IS UNLAWFUL. AND SHAi;6 SUBJECT AN 1 MPLOYER TO CRIMINAL PENALIM AND CIVIL MINES UP TO ONE HUNDRED "MSAND'D(XLAR8 (3100,D0o.), IN A TO THE COST OF COMPENSA'f'fON, INTEREST, ATTORNEY'S ftes, AND DAMAGE'S AS PROVIDED F E ON 3706 OF THE LABOR CODE= (a nature otC-67110ormed autttorbnd nprWaantWwL hemby author*& Ouft nam*) � G ane (1) year and is 11mfhd to the worts ptan Mod on the front pogo of this ■ppileatfon.