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69/11/2006 12:51 707823415@ WEEKS DRILLING• PAGE 02 <br /> San,Inggldn Bounty Environmental Hc"gM DpparVrrpnt unit IV Wall POWAMAPPlleetlon aupplonr3rnt <br /> JOB ADDRE95:_ PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION 1Lw <br /> I hereby amrm trial I am 11censed under the provlStons of GhnpW 9(rnmmpncing with Section 7760p)of Division <br /> 3 of tho F3Wness and Pr'OfegSiOnS Code and my{Icen9e i9 in full forte and effect / <br /> E. iration Vctot 9 A/W <br /> Date: Corftcto r. WP c <br /> Met <br /> Printed name: S �. <br /> WORKLRS, COMPENSATION DECLARATION , <br /> I hereby affirm under penally of pedwyr One of the following declarations, (CRECK ONE) <br /> —I have and V411 marr"n a oort4fc3te of consent 10 Self-insure for worrers'comperTesiitfi,its prOvtdad fbr <br /> by Section 3700 of ft Lab=Code,for the pertbMwnce of the work for whioh this Wmiu t Is issued. <br /> 41 have and will rnalt ain vwrKers'mmPensatton Insuronce,as requlrod by 9ecCon 37(16 athe Latwr COd2, <br /> feu ince ani o ante df the work for wfllch this fwd l3 f9aued. My workers'compen&ftn inaurarrce <br /> P cy numnma ate; <br /> Carrier:.5-fn}f. F s <br /> Palley Number: 11025.5-52555.- 22 <br /> 1 f=rgfyihat In Crc performeno®of the MMrk'mrwhiOtl this permlt I9 Issued, I Shap riot employ any person in <br /> any manner so as to became subject to the warksrV oornpetteetion laws Of Cal fcnlie,mmt free that If 1 <br /> 9110rrrd h com a Syq�aw omviWorkers'cOmPOnsatlon Provision of 3sction 3706 of the Labor Code,I ahail <br /> forthwllh comply vartll these PNVl3fons, <br /> ExpiMfion b0ke: 1 C3 SigDabmI <br /> 0 f <br /> PKnftad Name: <br /> W Anile G:FAILURERWAINA Trw uR6 W V RIiC .9,COMPENSA TION CGVRRAGE is UNLAWFUL,AND SHALL SUWCCr <br /> �ROVAN E'AIIPLOYFR To CRUYIINAL PENALTIFA AND CW FFNF_S MIP To ONF NUNDRCD T"ou&AND Dow <br /> fill sss.i,IN ADDITION TO THP COST OF COMPGNBATION,IMT6RrST,ATTORNEY'S FEES AND pAAR$ A9 <br /> f M FQR IN SECTION 9766 OF T149 LA MOR CODC, <br /> AUTHORIZATION FOR 220 THAN C-S7 SIGNING PERMIT APPLICATION <br /> I, <br /> (srgeamre OW-57 licensed auaxorhed wprmantapvrt7, <br /> nai:bp euvrortxe(pant mime► <br /> to sign lois Sawn Joaquin Cewlly Nrgll Perm t Appllaapan on my bchaN. I undermand trig su"wfbati3n Is valid far <br /> ono(1)Year and is nmttvd to the worn pun OiRfwd on#Ro"no page of t4ft oppa"Hen. <br /> 8-29 INr <br /> EHD27-Oy-0Cll <br /> fi/17/d4 <br />