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JVVAL)LJKCJ�: VCCiaCnLAL u1en uH wi renmrrw <br /> Fresno AvP., 5tacKton, CA <br /> LICENSED CONTRACTORS ECLARATION <br /> I hereby affirm that I am licensed under the provisions of chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code, and my license is In full force and effect. <br /> Ucensc it C57 554979 Expiration Date p1 -31 -01 <br /> r <br /> Date July 9 1999 Contractor West llazmat Drilling Corp <br /> Signature <br /> cr man , _ rrc a a <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of per)ury one of the following declarations: <br /> I have and will maintain a certificate of consent to self-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'oompensabon 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 camcr <br /> and policy number are <br /> Carrier Tra v L 1 C r s Insurance Co poscy Number IJB982KO2799 <br /> I <br /> I certify that In the performance of the work for Which this permit Is issued, I shall not employ any pCrson in <br /> any manner so as to become subject to the workers'compensation 1.4tills of California, and agree that if I <br /> should become sublP t to the workers-compensation provisions Ion 37DO of the Labor Code. I shall <br /> furthwdh comply with those provisions. <br /> Date July 9 , 1999 Signature: r ars-,TUr-- <br /> cra a an, is <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COV GE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO O E HUNDRED THOUSAND DOLLARS <br /> (100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 7706 OF <br /> THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. <br /> 'c d <br />