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WILLIAM DUROVSKYliI.�IRONENTAL NO. : 408 253 s ]f <br /> r <br /> �j P03 <br /> JOB.ADDRE83: 2373 Mariposa Road , StocktonOM <br /> PK�#, � F-J <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby Minn that I am 00e115ed under the provisions of Chapter 9(commencing with Section 70M of Division <br /> 3 of tin Business and Professions Code, and my Iicenh is in full force and effect. <br /> Licosa• 604987 <br /> Expiration Drs 0 279t9i0 <br /> 11 <br /> Dim7 21 /90 Ontraoklr_'16 Drilling <br /> Ott <br /> ,6111145RKERS' MPENSATION DECLARATION <br /> s <br /> I hereby affirm under penalty of perjury one of the following declarations- <br /> I have and will maintain a oertiflosto of consent to aolf insure for workers'compensation, as provided for by <br /> Seotlon 3700 of the Labor Code,for the perfomnance of the work for which this permit Is Issued. <br /> I have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> for the Perbrmence of the work for which this Partin is issued. My workers'compensation Insurance carrier <br /> and policy number are <br /> Gamier�' "N41 CQ m!- 1 J 4 �ry 9 kky PoNumber S_ [ X00 P Srs—alt <br /> I Certify that in the performance of the work for which this permit is Issued, I shall not employ any person in <br /> any manner so ve to become subject to the workers'compeneston laws of CaOforie,and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 the Labor Code, I shall <br /> fort)with comply with those provisions. <br /> Data_ 7 ► ZZ—nl.q tsgnatun: <br /> WARNING:PAILURN TO SECURE WORKERS'OOMPENaATION OR Is UNLA ND!HALL SUIIIJECT <br /> AN EtIILOVER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO HUNDRED T USAND DOLLARS <br /> (100,000),IN ADDITION TO THE COST OF COMM. DAMAOES AS PROVIDED R IN SECTION 1706 OF <br /> THE LABOR.CODE.INT1e�ANDATTORIW-8 F!JM& <br /> F 'A <br /> I+If1:•1 i I.1'r! I +R <br />