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06 / 24/ 2003 10 : 44 7078234? ' WEEKS DRILLING PAGE 02 <br /> dury - 24 -0E 10 : 49 AM E INC . <br /> " ' �• 4a i�0a 7Y�f 909 bw9 955E P , 02 <br /> FIFTH FLrXF <br /> PA� 03 <br /> Ilan .laa —fI—� <br /> 1 Nuln Caun�:Bnrtronmenrel HepllhDap��m ant unit IV <br /> JO�t A Wall Perrnit <br /> DORSS:�,Z, LQr� �j rrGlr✓ APlkgifon syppiimini <br /> PERMIT 9l2fz,` <br /> LICENSED CONTRACTOR <br /> �i DECLARATION (�) <br /> 1 hereby g9wm that i am !!Comer under the proviSionqCha ter B <br /> Of tha Sadness and F're1e8F Coda .grtd mYIicBnse <br /> 81on P (Commencing wlih %901040nen 7000) of Olvlslon <br /> la In full feree and edict, <br /> License #; C67 77 (p �F <br /> Oats; 3VptrgnonData ZDO <br /> eEKS �rll_IiYlp, ' <br /> SlAnaturel� l® _r <br /> ` Tills: <br /> I Pfinfad �ama: �� <br /> i <br /> WORKEI7W CDINPENSATION ORCLARATION <br /> 1 hereby affirm under penalty of perjury One Of the fcllewtng tieclBrBapnB; (CHECK ALL THAT APPLY) <br /> I hove and will malnlnin a rerficetet of eonBent to sOlfdnkire for workers• compensation, ea provided for by <br /> Section 3700 cf the Labor Code, for the performance of the work for which this permit Is Issued. <br /> 1 nave and will rnainlain workers' WmPansstiOn insuranC ®, as required by 9aCt:on 9700 of the Lobar Gode, <br /> for the perIormance of the work for which this permlt Is Ir C OF required <br /> workers' txmtri 3700 of he Labor <br /> carrier and policy num ers are! <br /> Policy Number.lLc <br /> I Oertify that in the Performance of the work for which thk poemit is Issued, I shall net emptayanyperson In <br /> any meimer Be as to pecom0 Bu15100 to the workers' Compensatten Iowa of aallfornim, anC apron that If t <br /> should become suplect to the wo,*N' oompensatlon prt visions o` IowSection 9700 rn the Lebo oode, t shall <br /> fORhwlth COMOly with those provisions. <br /> Date: <br /> Printed Noma; <br /> WARNING: FAILURE TO SICURC WORKERS' COMFCNSATiON COveRAgE IS UNLAWFUL, AND SHALL SUBJNCT <br /> AN EMPLOVCA TO CRIMINAL I'MALT112a AND CIVIL, AWRS Lip 70 ONE <br /> I (7100lCOML IN AODtTION TO THE COST OF COMPENSATION, Ik TEREST',HUNDREDTHCUBANo DOLLARS <br /> ATTO <br /> PROVIDED FOR IN SECTION 7708 OF THM LABOR CODE. RNEY'S FEES, AND DAMAGES AS i <br /> i, <br /> (Bigltature 011047 iieeneed authorized representative), <br /> hereby puthopq♦ forint name) Jr A r y. � <br /> loslpe this Son Joaquin County Well PemdtAppllestlOn an my hahelt 1 ynderetand this ,Who �.� for <br /> j dxatlgn Is valid for <br /> Dna (1) traar and lq Bmitod to the wort plan dated eq the pont pa ye of this apppggttdn. <br /> i <br />