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O.L 19166385611 <br /> 20 F. CRSCRDDRILLING INC <br /> PAGE 19: A.t i VLO -bi ilY:7�r JLLVVi- <br /> _.E. ` r `. 04 <br /> f o i`1 1 <br /> i <br /> Ban.foatiuin County Emironnrentai"welth Ger vk**,Unlit N Well Permit A901catilan Supplement i <br /> JOB ADDRESS-.1a!, PERMIT SRS: <br /> i <br /> LICENSED CONTRACTORS DECLARATION j <br /> 1 <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(kornrneneing wfth Soot ion fWO)of Division <br /> 3 of the Sus;ness and Professions Code and my license is in fun force'end affect. <br /> License#: .- --�_� .1 -7 91 �_ Expiratiar, _� �_ o <br /> Date:q- rtuactor: 1rk <br /> 51(�nature: _ T111a:'MMAM5 Ma-M- LD14 <br /> Printed name: <br /> 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one 7f the following decleratioris: (CHECK ALL THAT APPLY) ' <br /> I have and will maintaln a certificate of consent to self-Insures for wprkere'compensation,as provided for by <br /> 1 5ecaon 3700 of the Labor Godes,for the performance of the work for,whits lhle perr111t Is Issued. <br /> I have erd will maintain workers'compensation Insurance.as reatilrod by Sac ion 371pQ of the tabor Code, <br /> for the peei!M mance of Ine work for which this permit is 4sued. My Workers'compensation Insurance <br /> carrier and policy numbers are: <br /> �4�� <br /> Carrier _� ��Policy Number F, �„+ <br /> I <br /> I certify that In the perf"Marm Of the work for which this pesnnit tsj lasered, I sleep not employ any person M <br /> any manner so as to become subject to the workers'Gompemsa#ion Is”of Cellfomla,and apve mat If f ' <br /> stiotaid become subject to MS workers'compensation provis Seed 3700 of the Labor Code.I shl it f <br /> forttrw V.comply with those provisions- <br /> r <br /> Otte: Slgrrature: <br /> Printed Name: v — <br /> WAItPIMG: FAILURE TO 39CURE WORKERS'COMPOSATIION COVERAGE 13 UPILAWHIL,AND 511ALL SUBJECT <br /> AN 1EMPLOVER TO CRIMINAL PERALTIES AND CAVIL FINES UP TO ONII?;HUNDRED THOUSAND DOLLARS <br /> ` ($1 Do,=,).IN AoloMON TO THE COST OF COMPENSATION,INTEREST f ATTORNLY19 FEES,AND DAMAaaB AS <br /> 3[ PROYIVED FOR IN SECTION 3706 OF TPM LAIkOR CODE. <br /> (slsnaturs'0' tC-5T licensed <br /> authorized rsprase+restive), ! <br /> narsby euQ1ar#,xe(06M n�1 I• <br /> to sign this son.Ieaauin County Wait hermit App"mim on my behalf. I!Nndsfstarkd this augpfftsWn is Val <br /> for <br /> onr t1)year and is Ifmited to the work plan dawd an dw froerk pow of this applimdfon. <br /> R <br /> lrt7�pD!}t M1 <br /> it <br /> b <br /> p3 3ov� <br /> i�(]G�� HL�T� E£4£89e6$Z TL �Ei 666E/b9lZi <br /> i <br /> } <br />