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01/06/2008 22:21 5306628052 WDC EXPLORATION PAGE 05/05 <br /> 12/27/2097 13:59 530b V26052 <br /> DEC-2?-2867 11'66WDC EXPLORATION <br /> CAM9RlA PAGE 93184 <br /> V27 93S 04149 P.83igd <br /> San JoaQu{n County L'nviroArtlRhtef rlosltff DepaTbndnt Unit N tNeN <br /> _ Ctx-,eor nkAp-- <br /> wiaSonh <br /> o,ae <br /> ercJOB ADDRESS: ed nsp* 7-6 <br /> 0 /� bK <br /> LICENSED CONTRACTORS DECLARA'nom (LCO <br /> 1 hereby usi; that 1 em Itowseorets o anode at!prCVi9iar19* CMtpter 8(t7o Mrrn&V with Simon 7000?�.'D1>rts}On <br /> 3 M the 8usine/sf5/and Prott!ss7ona Code,,,d my r;cansa 19 yrs RtII fonts and effect. <br /> �ICBnEr��; 'J y4��i y <br /> --�`�� <br /> Oats: !2 a Contratxor ^— ~. <br /> 7< s <br /> Signatunr — ---- <br /> Two: .S' <br /> Printed name: <br /> WORKERS°COMPEN9A710N AeCLAFjA7)0N <br /> 1 herotiy atRrrn ryl*r per"of P1ury one of the following dec2ar2WM4: (CHECK ONE) <br /> ;have add will 0 otRu0Of ate <br /> Q1f!;Taction 3700a t�f ate of cmusrR 90 seff`in9Nre fbr"rkeml eampensw,,,as-Irvwji!d for <br /> 1Dar Cook for the Perfomram*of the wtxk for which t w pear!!!it is'Wed, <br /> I have and wit maintain warRm,ccmpwwatfon;^ .as <br /> tot the perfam+ane*d the work for which trtls "�br Section 3TQD of the l.ntsr Coosa, <br /> carder and pohcy f>urtb"are. permrT is 14fluerl. W wdrtollra'carnperrsatim iZ auranc <br /> Carrier: -�/t lC� flt!'1 1Z5Polley Numbor"�_ 0 '7SW <br /> 1�w _..LL. <br /> h'That iR the performance of um work for which this permit is lasued.f s�hoa not em <br /> Y mannTtrae TM to became sutalset to thm workers'compensation taws of Cas boy my powson in <br /> ShOUR►r M eubjW to Vag trrorlQw6*eornpen9eeon prorrteiena d iia'fa and aSlrse fna� tf 1 <br /> °OmPh'wAh VMW proApiens. rook <br /> Drpirstion Date. <br /> Prirt+ted NTtme' <br /> WARWja2z FA LURE TOBECWC WORKERS'COMP <br /> AA(EMPLOM TO C"MAL PENALTMG ANo _AOC b T1Nt.AWPUL ASO S LLI SLt1'.r-CT <br /> 9106.00e J,IN ADOrrl*N TO THE COST of C PQMCIITIONUP T ID OW,"WORM A��gou"No COUAPA <br /> RCJVtt]Ep ROR W Sr'c" M 37100 OF OOR COTE, FM,ANO nAMAOC':it9 <br /> AUTHORIZATION THAN CS7 SIGNING PERMIT APPUCAT10N <br /> t' ianslur9 c&-s7 roeunedd wAhorbod <br /> MrrbY auetorttee(prier!narna! rroressnt:,na.,). <br /> to algn this Sen Joaquin CountyV0ell Pwmft App*cavon on my behalf. I wrdeftle"lhla raut}+vrizatlon Is ralb for <br /> one(11 year and is Kned"to the work ptan deter!on tht herr!We a this opolioallon_ <br /> 2•tD r1 t?2.00l <br /> inamd <br />