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04/11/2006 19:12 92533504£33 GREGG DRILLING PAGE 02 <br /> San Joaquin County EmArunmentat Meath Deparbnant Unk IV Wall Penult Application SUpplcinwd <br /> JOB ADDRESS: Z/,/00 6nfi St-PERMT SRx. <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hereby aiflrftl t am licensed under to provisions of Chapter 9(commencing with Section 700)of Dlvlsian <br /> 3 of the i3u sines and Professions Code and my license is in fu0 tate and effect. <br /> Ijcanset d SI U5 EJpimaliarlDaae:- 1-'Ji-C>R <br /> Date. Contractor t (_'CiG_ �1�1 C> a , �VlC'✓ <br /> Signature• ��r� Tile., <br /> w. <br /> Printed nan - <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affmn under penalty of perm ase or Nte bwoMng dadaraborm (CHECK ONE) <br /> I have ant dfine maintain a cedificale el amserd to selFiesum for workeW eompenaatbn,as provided for <br /> _...,by Section 37M Of the 1_211a Code,for the Txviamnance of the wok for vMicb tins panni[is mrsuea. <br /> I have and vO maintain workeie compensation Insurance-as reWlred by SecOon 3700 of the Labor Code, <br /> far the peuWan nOe Of 4W watt for Which this pelmd is issued_ Illi vtOrrrsrs'ka:rwerrsa0on instmance <br /> carrier and Wm.�y.numbers are: <br /> Carder_ �L �Jir I Poncy Number PDP,) )b C:5 6Z(0 I <br /> I celWy fttat in the perfamrance of the work for whirr this permit is issued,I stall not empby any person in <br /> any manner so as to Demme%4W to ft workers'compensatbn laws at Cattfanie,and agree that#I <br /> should betAme subject to the workers'cannpermalkm prnviaiats Of Section 37W of the Lacor Cone.I shall <br /> foMmit r wmlpy with muse provisions. <br /> Printed Name: ( (G <br /> WARNING FAILURE TO SECURE W)RrKERS'COMPEWAYION cUYERAaE is uNLAMIFUL.AN0 aHALL SuajecT <br /> AN IFRWUWER TOCRINaNAL PEITALTES Alm CML FINES Up To ONE#4UNORED-MOUSM DOUARS <br /> (ftcc oca' IN ADOTIION YO THE COST OF 00111PE"SAT IK INTEREST,ATTORNEYS FEES,AND DAMOAKS AS <br /> PROVIOM FOR at SECTION 3700 OF TRE LABOR CODE. <br /> AUTHORIZATION FOR 12 THAN C-87 SIGNING PERMIT APPLICATION <br /> I <br /> a.{r L U//1l� � ., y <br /> Ltd CQ _ (�sbneLrre CM47 lmnmd saIlledzW repmsenlsave{ <br /> hlmpYaulkwire mal 4,11LA /17:✓�/ L///,5 �j [�✓ <br /> d� <br /> to sign[tris San Joaquin County Wan Permit AppFaikm an dry bdalf, lmWerstand ibis aotborultiun is tylia for <br /> woe(1)year and Is limited to the work plan dared an ane boat pays of thb nppiicaUan. . <br /> a-2M21 w <br /> Ego 29-02-not <br /> �axro� <br />