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10/16/03 THU 09:21 FAX 925 363 7275 TERRA VAC NOR CAL Q006 <br /> San Joaquin County Environmental FI kh Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2103 Covn`{f-sl Cl06 /jiv.P PERMIT SR#: & 157 .up3 / <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: C57 #552198 Expiration Date: 6/30/05 <br /> Date: Oct. 17,43 tractor: Western Strata Exploration, Inc. <br /> Signature: . ---_ Title president <br /> Printedname: Svlvie Jense <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under Penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-ineure for workers'compensation,as provided for <br /> Zby Section 3700 of the Labor Cade,for the performance of the work for which this perTnit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Winn & CO Policy Number: 1569784-03 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should became subject to the workers'compensation provisionsof on 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Oct. 17, 2003 Signature.• <br /> Printed Name: Sylvie Jensen <br /> WARNING: FAILURE TO SECURE WORKERS'COMPE ON COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL NES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=700,000.),IN ADDITION TO THE COST OF COMPE ATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR ODE. <br /> AUTHORIZATION FORTHE HAN C-57 SIGNING PERMIT APPLICATION <br /> 1' (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin Cou e8 Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and Is limited the work plan dated on the front page of this application. <br /> 8-29-02 i M1 <br />