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FROM ': FRONTIER DRILLING � FAX NO. 209 669 0211 ' Feb. 12 2001�02:50PN P2 <br /> f fCb 12 � 48a WriF� irtG . f'nG'` 0s <br /> Q1 11 <br /> FLC,1J� <br /> 02/1001, t�2Fip �DS� abe34 3 Fr <br /> T - 1lcatioo Supplement <br /> a <br /> ssn, CC1L1tty <br /> s=tr�f[o t�1 Hmtth Se Cos,Unit 1YWel1 Pr,rrnit App <br /> PIER1M1T Ste:_ . <br /> FSS: <br /> 3w,�CEMS� <br /> CONTRACTORS 'DECLARATION � ) <br /> tti thal!xur Tioenac�!unt�ry the provWwa of Chapter 9(ttrtttmencin9 x t:Qt1 70itp;cf D1vI5iQn I <br /> n6ss and prnf�1�Code and MY 11CV)Se��full tar:a 8nd refect. <br /> _. _ / CO�rlracror. l2�T + <br /> T'Itte: 9 <br /> $iQnxtttr�la: <br /> PrInW name: <br /> �^ <br /> WORKERS' GaNtMNSAIION DCCLARATION <br /> j i hcrcby affmm under penalty of per ury ene of tl,H kdtcwing ueeforationr- (CHECK ALL THAT APPLY) <br /> _t have w�l meitlWn a cxttificala of carrcp60*ati0mto,ptt'fit i5 issuidOd for by <br /> S+eCtion 370Q of ibe Labor Cof.for the pe crmartt�a d tttP work err w1t dt tiris <br /> I have"wi11 malntsin workers'compen56tion k-ml WCO, uu rcgLdred by Section 3700 of`.he LuWr C-Odc, <br /> for the perfarmartee of the work f0'wtllch t`tls pernaii hr ;s r 1- My workers'compen2 ruVoo icr uranGe <br /> =rior find poli nu b ore: <br /> Card o r. <br /> CA- policytNun*a - <br /> I r:afh'ty that in the pedarrndn 9 of the work for wWeh this parmA is issued.I tahall not wnplay any persuai W) <br /> any manner>so ns to bmome subject tr7 the Nwrkers'W!ponrsatkx►1�W5 of Califumiu.a r zx aK?rca tttdl" <br /> W%dWd baaorna au0j*et to file worker,'carnpensati<or, prot4slona d tier►3700 or me 1_ahor Code,,1 sh:d <br /> f6ehwRh mmply rwth U-sc lumvisYOns <br /> two.,�/��Signature: <br /> PrintaCl lit►' <br /> WARMVJG_FAtWIM TO SUCURg wOKKERS,C05bTIQN COYMRACW is UNLAWF-UV_ARID SHALL.SLNWECT <br /> AN DAPLO`LR Tri cRil+taVAL_PENALTT"A14D CMIL FOWS UP TO OW HUMUR&M THOUSAND DOLLARS <br /> (ZjgQ,gDq,),INAl]'BITION TQ THE COST OF COMPM45"ON,WtREST,ATTORNErS FM,AIV DAMAGES AS <br /> PROW IM Fog IN BECTT4ls 37W 0F THE LAELUR CWE <br /> I— lluttssd outhurixnd o'C>Preaentative),heroby <br /> 1 xe�n <br /> t xe algn thiL San Jaaquln CountyWou Arrmx Apptt=Icn on my behalf. 1 undtuatand thls av`.hu-Lm an la Vaud tot <br /> arta t'tl YNW and Is minvAa to thowark ptm dswd on the how P20e of this amcFtuliee. <br /> W, /U7 <br /> l / <br /> Frorr, M CHAE'.RQ2£RTS To fr R,STEVE Date 2!910 i ',rnr:$.53:26 Ayt Nage s or e <br />