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Oct 14 05 09: 53a GREGG DRILLING 9253130302 p. 2 <br /> 10/14/2005 09:49 9253130?'' GREGG DRILLING PAbt 02 <br /> NO.757 P_2 <br /> 7 <br /> San Joaquin County Environmental Health Doporbnent Unit IY Won Permit A0prrmtlon Suppfarnant <br /> .JOB ADDRESS* PERMIT SRS• <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby 8tf4rtn that 1 asci ficanmW under site provisions of Chapter 9(commencing with Section 700a)of Division <br /> 3 of the Butaness orad ProfBssions Code and my limnse is M full tbroe and effect. <br /> License 8. Expiration Date: �3 t eLa <br /> Dace: t C) I �k l o`s G,ntra`cmrn_ G rrQr, �,xy <br /> Signsllrnoe �� ( TIOW <br /> Printed name: �74 a rV CA -)U ,—L Ci C4-1 <br /> WORMW COMPENSATION DECLARATION <br /> I hfm*affirm under penalty Of PSdUrY orte of the tdluwkV declaraerons: (CHECK ONE) <br /> 1 have and vA mairftin a oa►gr=te of consent to gelRhtsurs Ibr worlrers'eort'tpertsation,as provided far <br /> by Section 3700 of the Labor 00de-for the Psrforrrtartoe of the work for which ods perrat ie issued. <br /> �I have and Ml maintain workers'coR,per=Wn kaurarlte,as lequh3d by gecupn 3700 of the tabor Code, <br /> for the Pealbnnorloe of tate wcv*for which this part is 140UW. My worimrs'companmflon insurance <br /> Conies and policy numbers err. <br /> Carrier: � �J V 1 QIAt— Policy Number: i Imo` z(D I <br /> 1 Certify that in the Performance of the work for which this pemllt Is hawed.l shall not employ arry person in <br /> any manner an as to become subject to fire woemM,eMpengoon Umn of Cafllontia,and agree that if 1 <br /> should be°ome etblect to the wortaers'OWpOnSafon ProvialOns of Sedon 3700 of the Labor Code,l shelf <br /> fvrtlWdh Comply wM those pravmWns. <br /> Expiraden Date: 8I l ftnaturo: r / <br /> PrWrtsd Flame• <br /> wARNINek t Mk]RE 710 s6t:uW vMORid?t.S'COLVENSATION CCVERAIM IS UNLAwFtn,ANP MALL SUEUECT <br /> AN i:WLOV"TO CRIMINAL PE1tAL"153 AND CML FINES Up TO brie H17NOREP 7HOU"M BOU ARg <br /> (5400,0ft).Of ADDITION TD THS COST OF C011MO 3AT10N,WMICST,ATWKMEY'S tEE-t3.AND DAMAGM AS <br /> PWMDBD FOR m SOCTION E7p6 Of THE LABOR COOS. <br /> AUTH(OORRI2� 110N'/F�OR 071lFR THAN C47 SIGNING PERMIT APPLICATION <br /> >. b -"'` Q. (sfpnatur+ow-a eulhoiOwdrepdaentat%m). <br /> rby <br /> heoun w ave(Prme <br /> int sa ) yl ,I/' r�l✓l � �-e Y, run 0, <br /> to sign tate San Jamfg%m Ceupty%Aelt Perris APPliMOM cn nay behdt 1 undema nd th es su"NW&izadon is valrd fw <br /> ora(1)yery and is I:rt dad to sloe work plan dated on the front page of 1171s appftation <br /> ■-79-0i2!Yl <br /> a <br /> am X0.02-001 <br /> 6MM4 <br />