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FROM West Hazmat FAX NO. 191663 613 Feb. 19 2002 12:.5(HM I'1 <br /> FEB 19 '02 12:22 FROM: '. <br /> T�128 P.Q2/02 F-119 <br /> 02/1j;/2002 08: 19 ?�9AbB 11 TA E I TH f 11�UR <br /> FILE HTY-1 <br /> I <br /> 00 1 <br /> ]per i <br /> I'�Y J 1j 1'I 4 I IY'' 4 •41 ' I I 7 I I I y I� I T L� I} • ,:'., I <br /> 4I1 <br /> G»�'' �' I til 1i II i I--� p '4u Sr , 1 ml i��a __!�' ..'fA' I. .k�YxSla• YT+t'-!'.;,�hC"- 4AtAl@I+rl" M' �. <br /> ',- <br /> ti <br /> hr, a <br /> .. .,. . _. .. � <br /> LICENSED CONTRACTORS DECLARATION L"C <br /> 3 of the Busiiness and Profe"lons rctdoedre and mI j�o is in If fi3fcs and a inp with Station 7000)of division <br /> end erect. <br /> Linenes# Eyc I Ic►ri <br /> pi lato: b/ - 3/ ' d <br /> Oats: XF <br /> Comm <br /> aloft . <br /> Two.. do - If 9-6 zr <br /> — .-- <br /> WORKERS" (;OMPL-NBA-1-10F I DECLARATION <br /> I hefeby affirm under penalty of pequry one of the f0Ibwin0 d rations: (CHECK ALL THAT APPI-Y) <br /> have and will maintain a cer"cate of consent to salNnou for workers'compensation, as provided for by <br /> So Aon 3700 of the labor Code. for the perfomagnoe of the work far which this plermlt is tamed. <br /> ✓Ie and will maintain workers'compeftaltion insurance, <br /> for the parfarawnce of the work for which his reqaired by gin 3'!f►o of tha Labor Code, <br /> carrier srrd pe" numbers tris: Permit is issu . My wOrk'" compensation invouratine <br /> Crrler: L4—:S ord)+•c1 /v S Policy Nu her:._ Z2,'"��l'L l <br /> I v that in the rmef�ce W �,� <br /> Einy manner so a$to bg rna subject to <br /> the workert;' rmF a tinr�,sws ar c�r�i not <br /> OmPbY anY Persnn in <br /> should beMMO subject to the waricors`rom)Wsatlon provis s Of Section 3700 of ftlaa�Gade, Ish�ail <br /> kwthwith oorrrply with those provisions. <br /> sinna p <br /> Prinftd Narn �f -.4 A • <br /> waWrulWr�:FAi"WK ro Br-Gu v 14cK�Rs �G1MP'AN EMPLOYER TO CRIMINAL PMAL.TIES AND CIVIL.F S UP TO E HU bREb TWUUSANa 13OU kS�gcr <br /> (i loo,nno.y,tN ADOMN ra THE COSY OF caMKNSAVION,INT EST,ATTI-;V R Eli�E6,ANp DAMAGiti�AS <br /> PROVIDED FOR IN SECTION 9706 OF TWE LASOR CODE. <br /> (G-s IJoormad authonwo reotw ardatival,I0nww <br /> to aegn thio tiara.Ion4ldn Cawtity YVoI!PWM It A � '�• <br /> ppllcation ori my paha . I undBANIand tl`t sluthaligisMan la vatld for <br /> acre 7 card 10 t work Iftt"Na an froa thlaapnn. <br /> �r <br />