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o <br />FROM : WILLIAM DUBOVSKY ENVIRONMENTAL PHONE NO. : 408 253 5026 P03 <br />1 <br />�a S' 2373 Mariposa Road , Stockton PERMIT#• 6A <br />0 0/99?5 <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70(]0 of Division <br />3 of the Business and Professions Code, and my license is in full force and effect. <br />License 0 604987 Expiration Date 10 <br />.` <br />Date 7/2 1 / 99 _� contractor HEW Drilling <br />Ry ubN(S <br />RKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations - <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, 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' compensation insurance Carrier <br />and policy number are: <br />Carrier 5 -f'4 -7-E C0i-.��. (� 4 . 't-eJU D Policy Number 00 <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 as to become subject to the workers' compensation laws of California, and agree that if 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.—, , A <br />Date 7 — -Z--29 Signature: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION LOGE IS UNLAV <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO OftE HUNDRED TF <br />(100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED <br />THE LABOR CODE, INTEREST, AI10 .4 i i ORNEY`s FEES. <br />AND SHALL SUBJECT <br />04NO DOLLARS <br />IN SECTION 3706 OF <br />