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n4 � 10:32 GEtLOOP DRILLING 4 19168610430 NO.9% D02 <br /> 04,'03.'02 RED 14:50 FAX 1 815 1" 1 0430 SECOR-SACRAMENTO IQIUU[ <br /> amp. <br /> OW J66*41 0W*6mvlfr,A171911hl ROOM Smites, Unit IV W40 Pt MIt ApptWjan Sint <br /> JOS ADDRESS: Oft, �) PERMIT SR#6: <br /> P-GAArN� P P f G °► <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby aff(rn th8l I am licensed~the provisions of Chapter S(Commencing with Section'1000)of Division <br /> 3 of the Business aandProfesaions Code and my kwse Is in full force arrol effect. <br /> License 0: 9, 3 <br /> Z Expiration Date: 4, - 30 - zec>z <br /> Data: y - - b Z- Contractor: ISM.. k b <br /> Signatu Title: fP C', � <br /> Printed nam: �-e►�,� Q �,. [ nn <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and vvill maintain a certificate of consent to self-insure for workers`Compensation, as provided for by <br /> Section 3700 of the Labor Cade,for the performance 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 performance of the work for which this permit is Issued. My workers'compensatlon Insurance <br /> earner and policy numbers are; <br /> Carrier: I�Q�IWPjP_..ti :�J PV{' sPoliey Nurnber: LSad <br /> _I cenify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workeW compensation laws of California, and agres raft 0 i <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. ! <br /> Ehft. 0S -;;,in —n-Z- Slgnamm - I <br /> Printed Narita: oQ <br /> wA :FA LURE TO SECURE WORCM,COMP04AN10N 00VW69 IS UNLAWFUL,AND SMALL SNBJECT <br /> AN EMPLOYER TO WKIPM PENALTIES AND CIVIL FV4S UP TO OM HUNDRED THOUSAND DOLLARS <br /> (St00,000).Nf ADDITION TO THE COST OF COMPINSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PNMDED trout IN SECTION 3706 OF THE LABOR CODE. <br /> 1 signature ofC-67 lloensed authairized mpmmn%tive� <br /> sumwtze Wr"name, Emit"t Ar*% Ell ..a <br /> to sign$No San JaaeLtn county well Permit Apptteetlon on my behalf. I undersand this authoriaMion Is valid for <br /> ora(f)yaw and Is Nndbed to Na wane plan dated on the Matt page of this application. <br /> g1T-2000/YI <br />