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y 98/28/2006 15:40 2098381723 WESTCOASTEXPLORATIO PAGE 02 <br /> i <br /> I <br /> San Joeauin County EnYlronmental health Deparlment Unit IV Well Pcm*Appllcagon Supplement <br /> JOB ADDRESS: j 5 QQ S- fsD PERMIT 8R#: <br /> LICENSED CONTRACTORS DECLARATION QqD <br /> I hereby affUm that I am ticeneed under the provisions of Chapter 9(commencing with Sedon 7000)of Division <br /> a of the Business and Professionst; <br /> Code and my ticense is in full force andct <br /> efferi <br /> Ucer"# ( <br /> U h-� -L :Ipiration Date: t l1 3 ! ` 0 v <br /> Date! b 0Cw*aCtt)r wt,~ _Ll}1t roL+Zc1Y� r� <br /> Sigm um: TIM: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations, (CHECK t7NE) <br /> t have end will maintain a outficate of consent to setflnsure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the perfomtanco of the work for which this pemA is lssuad. <br /> _I have and will maintain worked compensation insurance,as required oy Section 3700 of the Labor Code, <br /> for the performance of the work for which this permh is Issued. My workers'coinpensatlon insurance <br /> carder and policy numbers alis: <br /> Carrier; -- Policy Number. <br /> I eortfy that In the performance of the work forwhich this permit in issued. I shall not employ any person In <br /> any manner so as to bacoms subject to tho worksrs'cornpensetion laws of Califomla,and agree shot 01 <br /> should became subjeot to the workers'compensation provi�of Section43700theLLabor0ode,1 shall <br /> forthwith comply with these provisions, d <br /> Expiration Date. 1 \ 0 Signature: �// lam!/// <br /> Prietad Noma: �C,lraj AL17�7-- <br /> WARNING;FAILURC TO 6E0URE WORt{ER8'COMPENeATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PEKALTIES AND CML FINES UP TO ONE HUNDRED YNDUSMD DOLLARS <br /> (s1eD,pee,),IN ADDr TION TO THE COST OF C'OMPENBATION,INTURCST,ATTORNEY'0 FL'E8,ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 DF THE LABOR COOL <br /> AUTHORIZATION FOR #N C-$7 sIQNING PERMIT APPLICATION <br /> yKnclr%a11-fcinnn((pL '� L �,�.tclans(t`ureo(C-S7licemaedeuth-orr-W�dnpresentakEveh <br /> hereby wdwriza(Print name? C&t „ ?;V�- 4�-1v�e S, A] q�0�, '10 <br /> to sign this San Joaquin County Well Permit Applleadon on my behalf. I undomftnd this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on atm front page of Phis appnceaon. <br /> 0-29-021 MI <br />