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07/13/2005 11:13 707823420 WEEKS DRILLING PAGE 02 <br /> San.loaquim County EmgronmorMar Neenh Deparbrlont Unit NW N Permlt Appticalicn Supplement <br /> JOB ADDRESS: � '� L a rcV, • ,� PERMIT $R#:_, <br /> LICENSED CONTRACTORS DECLAPATIONL( CD) <br /> 1 hereby affirm that I am r1rnnsed under the provisions of Chapter 6(comy rioncing with Section 7000)of Division <br /> 3 of the Business�afdd <br /> n �Prrofessions Code and my license Is In full force an, effect. <br /> LicenI <br /> S:oo I z(0 R 1 _ Expkation Date: 0 <br /> Date: Carttrecicr. . i <br /> Signature This: lam_ <br /> Printed name: ( 5 0 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and win maintain a certificate of consent to self-insure for wo ers'compensation,as provided for <br /> by Section 370D of the Labor Code, for the performance of the work r which this permit Is Issued. <br /> I have end will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is issued. My rkers'compensation Insurance <br /> carrier and <br /> 11policy numbers are: ����� ��_�U'iSUrgnCC <br /> Carrion 5�2.Ud��Lind2 tL10�_..Policy Number <br /> 1 certify that in the performance of the work for which this permit IS issued, I shall net employ any person In <br /> any manner so as to become subject to the wnruers-Compensation laws Of California,and agree that if f <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwMh comply with those provisions. <br /> 1 <br /> Expiration Date: 1 I S Sl nature: <br /> Printed Name: ta 1, o ,50 <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGII IS UNLAWFUL,AND$HALL SUBJECT <br /> AN CMPLOYGR TO CRIMINAL PtZNALTICS AND CIVIL PINES VP TO ONE HUNDRED THOUSAND DOLLARS <br /> (91DO,000•),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,A ORNErS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTNER THAN C-57 SIGNI PERMIT APPLICATION <br /> I, (signature o licensed authorized representative), <br /> i <br /> hereby authorize(printname <br /> to algn this San Joaquin County well Permit Application on my behalf. 1 an denglend 9de authoev%tion Is valid for <br /> on*(1)year and is nmited to the v rk plan dated On the front page Of WS a ppilintlen. <br /> e-ss-oa r MI <br /> IIFIU 29.o2oui <br /> w�2ioa <br />