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FROM. : West Hazmat FP4 NO. 19166388613 _ Jan. 07 2000 05:53PM P1 <br /> 81/8712888 12:5a 289467 AGE STOCKTON �J PAGE 81/91 <br /> { ..-..c" � •'i" ~_'^,,.'.S:t Sint.•^^Li <br /> Rem <br /> •�•�.• r,.�•.,y;•�.�• <br /> .LICENSED CONTRACTORS DECLARATION ILCDI <br /> ereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Divii ion <br /> 3 ��� �tTBid31YiBIsE14LrfJ1 �it Section 7000 of Dtvta►on <br /> Li rad 6uebriau and PrABBlone Code)and my kanse is in full farce and effect. <br /> Expiration Date: <br /> DjPointed <br /> awarse V EWndon Data:on ractor.Doe., � Con <br /> Snature: Titl <br /> Title:Prated na e <br /> name: k <br /> gg CCep�pp pp nn GGII <br /> CQMP�►T�IIl�i7�i�1�N <br /> I 1 Mr, rn und+ re�er+I�yo���N7Y���i f ,Y�$� �I��$n�CP�E���I�LAf&TM , PLY) <br /> ecal <br /> nd will <br /> mit,al <br /> o I?Sr �fd ' riRmSlili r�( 5ued. <br /> „� Pray slt �ls :* �I +i � e I'.�t`�OatIt09�0'+fafLtileaktOoleG e, <br /> 1R>�i ERc�fdIltii �lirWt$OIQh t�li6rntiildssdM�AyroNvrrleApo�ro�rl¢eti�)Rewance <br /> carrom "W16roob: <br /> arderri r: I�iL��Fi�3fiftS'e O <br /> fttfiatl�Iti41� P1�3) @19t1E 1 �D'88� r r �f a 1 aio� nr°° so in <br /> 211y�tfyl4firrurcmi=18UV ttVtff@ <br /> shod t I � rovisions o ectt on 0 of the a or Cg de I a <br /> fort t �� pall <br /> Da jpate: 1~,7- <br /> SiVIMILI e: <br /> Pr1 t Namd: + *+ �j <br /> Printne Name. <br /> 1 : RE TO SECURE WORKERS'COMPEN6ATION COVERAGE W UNLAWFUL,AND SHALL SUBJECT <br /> A iL� n11d$ $(Il@tl�t1RNG�iRFN9K9Id~Nr� 9� fl SU J CT <br /> j?,tfiQ►l S7I4RDMRSM3WR�t#. #! p <br /> {S1 QJCItb �!(��iD�FI» 'Rl ��ION, INTEREST,ATTORNEY'S FEES,AND DAMAGES S <br /> PR DVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> l tr¢.�rt1+e �nC Yti� <br /> -(C-57 license holder).hereby <br /> a cnxa �titi$ARr by <br /> au �r �e , iratlht�hltia9ill��ern this an <br /> JO %onaWw"BM" I bkV d(W9 tWcmgUiYts authorization is valid for one(1)year <br /> an 1-dated on a ron page of this application. <br /> 1 <br /> 5 <br />