Laserfiche WebLink
I �l <br /> Ii <br /> Darpetro , Inc . <br /> IJOB ADDRESS : 749 E , Charter Way , Stockton pERRA1T#: <br />'r <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provision$ of Chapter 9 (commencing with Section 7000 of Division <br /> 3 df ?40 80609a c7nd P(Ofoul0AS Got and my IIW1m i5 In Yl force and effect. <br /> License # CA 57656407 Expiration Date15.pz Z.�Lzct_ <br /> DBte 8 28 ntractor. . + GREGG Drilling & Testing , Inc . <br /> Signature <br /> WORKERS' 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' compen$atlon , as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> l have and will maintain workers' compen0tion 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 �agl Q ,J Policy Number <br /> 5 V � <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. <br /> Date 01 Signature: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN E�'1PL Y15 TP 9FJMf NAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,000 ), IN ADDITION TO THE COST OF COMPENSATION, OAMA00 A5 AAMAW 6qR 1u S�CTI��15305 aF <br /> THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES . __ <br />