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FROM : WILLIAM DUSOVSKY ENVI 'MENTAL PHONE NO. : 408 253 5026 ..r P03 <br /> 2373 Mariposa Road , Stockton PERMIT#-. <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 0 (commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code, end my license is in full force and effect_ <br /> License if 604987 ' Expiration Date /0 (31 zec o <br /> Date 7/71 /q9 _L /-,Pontraclor_ HEW Drilling <br /> signatu N P-Y 0,b N G <br /> 14NORIKERS' C MPENSATION 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 sclf-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 Iacl-E CC t c( 1y� 4 't-t lO O Policy Number 0 OC r <br /> I certify that in the performance of the work for which this permit is issued, 1 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 1 - ZZ-�q Signature: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CO GE IS UNLAW , AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO O HUNDRED T USAND DOLLARS I <br /> (100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED R IN SECTION 1706 OF <br /> THE LABOR COOS, INTEREST, AND ATTI ORNEY'S FEES <br />