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Sent By: Gregg Drilling & Testing,.; 925 313 0302; Aug-3-Ct 13:44; Page 2/2 <br /> amroai�aoa �q:47 2ES4683d w FIFTH FLOOR PAGE 03 <br /> San Joaquin County F7rvironrtt9ntaf HaWjh Sarvic",Unit Wal Permit AWWAtbh Suppiamant <br /> JO�B1MORESS: Q, wr X1.11 D;D� 411a.,rL"' �,�,-5 &i** RMIT SRS' �Z ? 3 <br /> l MA9V Ori/ N SC4O:im r-r <br /> LICENSE CONTRACTORS DECLARATION LC <br /> I hereby affirm that I term licensed under the provisions of Chapter a(commuming with Section 7000)of Dmaign <br /> 3 of the Businessand Professions Code and my Ncence is In full force and effect. <br /> l <br /> Liomw#: OBJ Icc ExpirationDbte: I 31 OL <br /> Date, gl3 I dl c <br /> 8lenaturr n Title; - <br /> Printed nere: t-t aWo ( -,I,.— <br /> 1NORKIR9'COMPENSATION DECLARATION <br /> I hereby aflYm under penalty of Paqury one of the following dedarauons. (CNBCdK AL1.THAT APPLY) <br /> _I have and will maintain a cw&j ante of=Mont to seRhinaura for worker..° as PWdd <br /> fer by <br /> Section 3700 of the Labor Code,for the pwfbrmanoe of the work for%okra this Pwmk Is Issued, <br /> Ihhaw <br /> and wffl maintain workom,eompwafftion Inazulance,as required by Section 87()0 of the Labor Coft <br /> performance of the work for which this permit is iseuad- Ally workers'compasation insufmce <br /> carrier and policy numbers are: <br /> Carrier _N{!J .GL �Q 1 Qit� <br /> f Polley Number, <br /> -Li cwtffy That In the performance of the work for which this permit is Issued, I shall not employ any person in <br /> any should <br /> nnerbecome <br /> so es to become subJeet to tiw w**Am'compensation laws of Colffomle,and agree thsl K I <br /> should becom®subject to Mme workers'compensation provisions of section 37W of the Leber Cada, I shad <br /> forthwith complyudat those provislons. <br /> fie: �� Signature: <br /> Printed Nems W GL- <br /> WARNING:FAILURE TO SECURQ YPORIUMW COMPENSATION COVERAGE m UNLAWFUL,AND SHALL SUEJECT <br /> AN EIMPLAYER To CRIMINAL P1111tALTIES AND CW fgWj UP To ONE HUNDRED THOUSAND DOLLARS <br /> (S1t10,t1oo.).IN ADOMN TO THE COST Of COMPENJITION,IMTERUT,ATTORNRY'S FEES,AND Dauaece AS <br /> PROVIDED FOR IN SECTION VMOF THE LAMM COOK, <br /> prreWre v146T Noensed aufttu"reprecgttgVft), <br /> herby authorize <br /> to sign MIU San Joaquin Oouttgr Wail Parma Appllea'I- am my bohmdf. I un6an&nd this auMorkaation is Valid for <br /> wr(1)YW sed is Ilmkod to the work plan dated on Vm front page ut this apptlafeon. <br /> 3.17 0/M <br />