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r 08/28/2006 15:40 2098381723 WESTCOASTEXPLORATIO PACE 02 <br /> Un dalsautn G0(ifitY beim trtrolitilt Haft Dombn nt W h N Wall fill*ANPii(;tf~,Ion SVPkwe"ll <br /> JOB ADDRESS: PERMIT SHM. <br /> UCENSED CONTRACTOR" DECLARATION Q Cn <br /> 1 hereby d&m that I am Ummed under the proWsWris of ChW6v 8(oon mw4k q with✓secGon 70M)of D'vilion <br /> $of Cta Buslnr„w and Pno%velons Coda and my Warm 1s in toll Woe surd aRaCt <br /> 000W tk �. <br /> � lJrptrailpn bate: <br /> D.W. q, 0 C,4X*-ftC7M <br /> tagratunt: T1tie: <br /> Printed name: , <br /> WORKERS'COMPENSATION DECLARATION <br /> I haraby trlhm under penalty o1 penury one of ltra tolo"oadaralWa- (CHICK OWE) <br /> I have and will maintain a carificate of Dom wd to!df4rmeo for wbdc"axnpetisadort,as provldrad for <br /> by SeuWn 3704 pf the Labs Code,for the performsnm of tM work for whM this permk la kaued. <br /> I have and W mahtalin workore oomPe m*,,xt insuramm,=r wpkad 17y Seatlon vm of ttte Labor code. <br /> for the PerfomW"of the,w**for which Na pamr t Is tsaved. My worker's'ooRperteadon Irtsurmwe <br /> can*and nolo numbam tire- <br /> Cartirrr: —Poky Nue Wm <br /> 106"that in the per<ormenca of ifte work for wfrtch thtl perMlt is issued.I ihle not employ any penin In <br /> any manner sou to become FA bjeot to the workers'oompensekton iatta of Catftmis,and sgrw o*if 1 <br /> should Ioaome aut�W to tt o workers'ew permamon pm of SeGfion;3TOM#*Labor 006ee,I SII <br /> tO[thwb comply with thosri provWone, (/ <br /> EXPlrlMon Dates jb--A]asignature: 1 <br /> Printed NORM• y��+Y� �1C�»n•-r� �' <br /> WAAtilna.FAIL J$M TO GEOLMVWAftKt'XX CoMprdiBATlOtf COvt:RnUl!M UW AVMUI,AFV SK&A.L SUBMW <br /> AN F-MMMM TO CRIWNAL POMI ES AND CML FtNeS UP To DRE HUMMD TvioltsA> o,toI.IJIRa <br /> (6100,0x0.),IN AIXXTUM TO THE OOST Or COUlPI tiMATM RIMMY,ATTORNLrlr)PEM AND DA10A4MS All <br /> PltO'YIDED FVA IN SaCTIOri 3-M OF Ti#e L.ASM 000r- <br /> AUT14ORLZATION FOR N C-57 SIGNING PERMIT APPLICATION <br /> 4�r r i n a n �177- afore ofG 37 Gmnree so to Aaad rep"mW, v*L <br /> W"by auttrarie(print nernat 'f A��-� �- .lamN C-me0. - <br /> to Aign tlri/SAM Jusqu)"C:OUMV WON P.rw9M"ItAli t an Aly behWM 1 u»dsr►tartd thN autborlsatforr Is wild for <br /> on.{t)year and is lJff*"b the rorfr piss dated on the trot pato of tri.applioodlorr. <br /> / <br /> G}ID 7s)-0Z-0D I <br /> 6r4lD4 <br /> Z8 �V'ti scsrtseaeBL G1k�59&AZ iG=b1: 4GOZ/flZ/Qa <br />