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FROM : West Hazmat FAX NO. 1916b38e613 Mar. 21 2000 11:05AM P1 03/21/2000 11:46 2094670 AGE STOCkTON 10 PAGE 01/01 22 2 F ��.tttt, �r�rr(✓rL �y{�y7 Q p/� ' a F F� S/ .!TTUQI'+N. H.�v +rl JOB ADDRESS ` PERAAI I" SRS 01 ZZ nr ',a ,e 3t r LICENSED CONTRACTORS DECI-ARATION ( ) I hereby affirm that I am licensed under the provisions of Chapter 9(commenting with Section 7000 of division 3 of the Business and Professions Code)and my license is in full force and effort License#: --.CS-q 9 '7 5 _Expiration Date: �6y 1/- zoo Date: 03 - zit!--toad_ Contractor tFsT- Slonalun• � 4.. L rye e Tido: d+,.+rr y ' ,. Printed na�rtt�l�+ c.+'.nr•-o ,Q i6�f0+e-c rz.�r'f— ' WORKERS' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) —I have and will maintain acenlfirate of consent to self-Insure for workers'compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, e for the pertermanee of the work for which this permit is issued. My workers'compensation Insurance carrier and policy numbers are: Carrier: . jr tµ iLjl.s AJS• Policy Number: Y �C'iJ� V46 98/145'14 2-67e I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to,the workers' Compensation laws of California, and agree that 41 should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. n /� /J Date: 21-206 co Signature' .+�J� Cl 114a,,zeA-e Printed Name'•_•�W�1'w.o �• �lyRa+�AtS� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL,PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS {A100;000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. (C•51 license holder), hereby authoriz< It e7-LAt L of _�LI4 fret J I" (eomsuiting),to slpn thle San Joaquin County Wall Permit Appilcatlon on my behalf. I understand this authorization Is valld for one (1)year and Is limited to the work plan dated on the front pogo of this application, y.;