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Sent By : Gregg Drilling & Testinr _ Inc . ; 925 313 0302 ; Oct - 2F 00 16 : 33 ; Page 1 / 1 <br /> td/ 1bI '1000 16: 06 53067E 15 STRATUS _ PAGE 01 <br /> I <br /> 05/ 15/ 2800 013: 21 3094683433 FIFTH FLOW PAGE 03 <br /> NIL, <br /> • t , Rp.. . . ik �w <br /> S le <br /> d?snrrlomrrIN k rentaitkl' erapt c,:u�it•Iva(�ati; P IT "Ply, Pit Ilk. <br /> a <br /> u. _ <br /> NIL <br /> INN I <br /> -Mll <br /> _ 0449.1 , 1 .. . <br /> NIL <br /> LICENSED CONTRACTORS DECLARATIONL( C,�IJ <br /> I hereby afiinin that I am licensed under the premaalons of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of tlra Business <br /> /and �Professions Code and my Dense is In full force and effect <br /> `i <br /> Licenseff , , Jl� o i Wrrration Date: <br /> Date: 2 © Contractor. _ llA t <br /> Signature. �_, - 9• ` :� Title: 51L <br /> Printed namal <br /> WORKERSO COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to salrAnsure for workers' compensation, as provided for by <br /> Sec ton 3700 of the Labor Code, for Ilk PeMnrience of the work for which this permit is issued. <br /> ✓I have and will maintain worker's' compermation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit la issued- My wotkers compensation Insurance <br /> carrier and policy numbers aro: <br /> Lf�S7 <br /> Carrier, F - Policy Number. � ooc <br /> 1 ow* that In the performance of the work for which this permit is Issued, Is <br /> trall not employ any person in <br /> any manner so as to become subject to the wufkera' compensation laws of 9a11Mmie, and agree that if i <br /> should beoorrre subject to the workers' compensation provisions of Section 3700 of the Labor Cod®. I shall <br /> forthwith comply with those pruv1510111I <br /> Date: jda.._'��-Zoot2. Signature; <br /> Printed Namo: ,�— <br /> WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGS IS UNLAWFUL, AND 914ALLSUal <br /> AN IWIN,OYER TO CRIMINAL PENALTntB AND CML f INL'S UP TO ONE w INDRED T"CUSAND DOLLARS <br /> INADDMQNTO <br /> a74e TIN LABOR CODE N, IN7ERE$T. ATTORNEY'S Fez s, AND DAtnA ®Ee AS <br /> P�ROViPEIr 0R IN <br /> I, �, .r,-, C�—N_'���— � I`�� ,.., fC.67lfeangd aulhwrized regraaentistive). hereby <br /> Autlwdanfor <br /> to sign s San Joaquin Courtly Wal Permit Applic0on on my behalf. 1 undarstand 'this authodza6an Is yarid <br /> rte <br /> ons 1 and la nmitad to kha wa+k ran datwd on !ne front a of this a paation. <br />