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Oct 14 05 09: 53a GREGG DRILLING 9253130302 P • 2 <br /> ,10/14/2005 09:49 92.53130302„ ,� GREGG DRILLING HAL-A-- U2 <br /> . . �.•virtv�eu-1.llvl., NO.757 P.2 <br /> San.0WMn County awtronmental"Sahh DaPertrnent Unit IV Wail PWM1tAPP%c:vftn Sq Wainartt <br /> JOS ADDRM; PERMIT SRX: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> i here!:)tf'm that t am ficenaad ur 4ar Cha provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Bueirtess end Professions Cade and MY Rcanse is In fedi fbree and effect, <br /> 0 <br /> Llcertss:#: l C. ` 0-7 Eq*'a!on Date: <br /> Date: t I `k �� Car{sact�er�_ -I-CP 01 A -{ u <br /> Printed came: L24 I I <br /> WORKERS'CCOPENSAMN DECLAitATION <br /> I hereby afimn under penalty of penury one of the tdowl rg dedararwm: (CHECK ONE) <br /> I h9ife and wr71 maintiain a oerif irate of co,tsem to"f-Fnaure fbr warlteW aompeneaf m as Prftded for <br /> by Section 3700 of the Labor Cade•for the performance of the want for which Utas permit ie issued. <br /> I have 2W w81 mairstain W0rlcers'C0""nsatian inatxance.as required by,3ectian 3700 of the Labor Code. <br /> for the performance of the waric for which this Perth is IsQued_ My workers'comperaation insurence <br /> carrier and DoW numbers are. <br /> Carrier: � L�'J� ) Pot icyNun+ber: <br /> I cartify that in the paforrnence of the work for which this pannit is issued.i shat)not employ arty person in <br /> any manner an as to become suOied to the 'ownpensabon lewa r►f Catltapria,and agree that If I <br /> should become to the worIWIV cornpertsatian prouWans of Section 3700 of The Labor Code,l shell <br /> forthwith Comply with those pra'fmns. <br /> Explradon Date:_ 8 i l 5'rgrmfu .. <br /> Prk fad Name: <br /> WARNING^FAILkM To 8ECtlRE!Vs0P.K r COLVIONSATIOU COVERA9X IS UNLAWFUL.AND 3HOLL SURJECT <br /> AN EMPLOYER TO CW LVkAL PERALyM AM CML FiNEs Ur TO Otic HUNDRED THOuumn DOLLARS <br /> (5`i00.OW)- IN ADDMON TD THE COST OF COMPE"ATWK"TFYtEST.ATiOMEY'S FEP.B.AND DAMAGES A9 <br /> PRc)v'E)'D FOR IN 31CT10N 37m of TmE LAam cone. <br /> AUTHORIZATION <br /> .�F/OR OTtI�R THAN C-67 SIGNING PERMIT APPUCATiC)N <br /> v` <br /> 1•� Q,� 1J�1 •� (stpnatum efC-67 euttwrtl+ed,ept asentrtira), <br /> hereby s e-2re(print rNumll, int/ 1 0- <br /> i -eK <br /> to rign thk San Joagnin Caur.tp Won Permit Appticadon on my behstL 1 w dwxft d this sveherization Is va0cl for <br /> tett(1)year sod is limited to the worst plan doted on the front page of"fls appfiratror4 <br /> ■-79-0r2!Yi <br /> a <br /> Elm 20.01-001 <br /> 6171JDa <br />