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02l0012B87 10:01 9253138382 GREGG DRILLING PAGE 03 <br /> FE73-0?-;n 16=22 916 362 8180 I 916 362 8100 P.03 <br /> / /�o-�- Au//5 we <br /> SM J*69Wn COY EAVIMNW RW 1400 Deparb Mnt Unft tV Wall Pam it APPWXU ut 8uWonW <br /> JOB ADDRESS <br /> �✓�,(.1u„.t p� S4r k, G4 pERmIT swx� 9� W <br /> LICENSED CONTRACTORS DECLARATIONL(_CD <br /> I hwaby aMrm itwt I am kmrtaW under U»prmisiom of Cl+>mow 9(cmhff andng with SeCSM 7000)of Dh sim <br /> 3 d the Su*MM and Proktsorss Cads and my AOW"is n hA force and affect. <br /> Li,mWr 485ibS' Eg*aOmDawe; (o13r 1 2.c-=A- <br /> Dow. a l s!aw�l Cb�( tir+rSn .e4+, Zmou <br /> 81pnatwo; �u�^' �as�F'--•�— Thim J_1Lm._---:ilF <br /> WORKERS'CONPENUTION DECI.ARAMN <br /> I hmoby affirm under pa+ahy of perjury one of th 1c pfft dacwwjorsa: (CHECK ONE) <br /> _I trams end wYt nraiMa+n a wrtiCatn d corarer+t m aalfinauw for rwdrara'mmP�M1�PmMdnd hr <br /> by Soebw 3700 of the Labor Code.fur the pwRwmarvm of the wOdt Por which WIa pwrnR k outrd. <br /> I have and wte mmk*dn wmikwsconposob t w w mmk ss required by Section 3700 of the Labor Cade. <br /> for the pw6wmwten of the work for which fts pem it is kared. My workers'compwmatbn(raven A <br /> oarrhr and policy niarms era: <br /> Carrs.,: P*NcyWvnbarc 3Q1�40ato1 <br /> f car*that In dre p&trmmim of hw work for which Ink peerst k kauad.i dare.rat si4*y any pmsm in <br /> b�00tXn�t�a to thio e w vA"d to�P Soclion a�d Ltborand"dW Codv i Eihal <br /> fardmith WnpV with @wee Wamiot a. ��++ <br /> Ewmaas 7otu shpwt m+ AS A.SnYwnrr .4.` <br /> prided K mK c_ ?-L-a C.H fu5TF.-r.t'� <br /> itfAttlf &FA AM TO 90CURE asOMOEFW COMPOWATM COWMAGE 19 U)A AV*UI�IUD MALL SUBJECT <br /> AN EMPLOM TO CRMAL P040A.TVS AND OW FNBS W TO ONE MM""n trSAMD UCA.L <br /> ( PQANi iF T10N� HE OP O COWAMM OATI K WMMT,A71Tki11E7'e FEJT.AND DAMAG s As <br /> FOR 001E RTHAN C47 alQNINC3 PERMItT APPLICATPN <br /> ----O*WAIa is OW-47 aawwr-*Wtrad nanemea Veit, <br /> araaa9lsulbatarfader+wmaL �rr� 7PZ <br /> m 04%"sae JatoMaw Canto Ww PWMN Appaeadan ae*9 trrrralf. f o,awst.nd aha mahadraom M whW for <br /> we(1)you mW 4 RafNad Is to work Ptah dead en dw"M pqe or so aypReaeon <br /> 5-"4210 <br /> no 2ILM401 <br /> TOtRr_ P.03 <br />