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i <br /> _ a <br /> 08/28/2006 15:40 2098381723 WESTCOASTEXPLORATIO PACE 02 <br /> I <br /> Ban Joaauin County Wrvnmentai Health Department Unit IV Wd Perm"Appilcation SWploment <br /> JOB ADDRESS: 1-15q0 �5. z; PEkmrr swt <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I em Ncsnsed under the provisions of Chapter 9(Commencing with Secdon 7000)of Division <br /> 3 of the Business and professions Code and my license is in full fore it and etfeck <br /> uceries# C I '-O t0 Enpiratlpn Date: t 3 ` O <br /> Date: b Zt 10 fo Cont solo W e tCnti ) r% �tuv. <br /> Signature: Wile:^ ✓ <br /> Printed name: <br /> WORKERS' COMPENSATION Dr:CWM ION <br /> I fieraby afflrm under penalty of penury one of the fallowing declarations., (CHECK ONE) <br /> I hairs and will maintain a catificate of consent to sethlnsum for workers'compensation,as provided for <br /> by Section 9700 of the Labor Code,for the pe4rmanc:e of the work for which this permit Is Issued. <br /> `I have and win maintain workers'compensation insurance,as required Dy Section 3700 of the Labor Code, <br /> fw the performance of the work for which this permit Is Issued. My workers'compensation insurance <br /> rwT*and policy numbers are, <br /> Carrier: Policy Number: <br /> I certify that In the perforrnance of the work for which this permit is issued, I shatf not employ any person In <br /> any manner so a6 to become aubject to the warkem'compensation laws of California,and agree that 01 <br /> should become subject to the workers'compensation provi of Section 8700 f the labor Code, I shat! <br /> forthwith comply with those provisions, <br /> Expiration Date: 1 \k O Signature: / <br /> Printed Na ,meCk,��17Z-�/a z— <br /> WARNING:FAILURC TO UECURE WORKERS'COMPENUA710H COVERAOE IS UNLAWFUL,AND Skein.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (s100,pe0,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEW,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LAIM CODE. <br /> /1 <br /> AUTHORIZATION FOR N C47 SIGNING PERMIT APPLICATION <br /> 1 ffndrr c I Ncincrn[(p� (6lgnature ofG57 ticamwo autholtmd repreiw(40ve), <br /> hereby authorize(print name] rc_tPYt��'`"44-t=lv _ n Y L; Aj (q-e 01 j�'t" <br /> to sign this SanAosquin County Well Permit Application an my behalf. 14nderstalyd this authorization Is vand for <br /> one(t)year and is limited to the work plan dated on the front pane of dela application. <br /> $4042100 <br />