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S-01-19-99 5:21PM FROM FISCH ENVIRONMENTAL 2097723571 P 2 <br /> Y <br /> C <br /> E <br /> P JOB ADDResS:_ llJ ►.o .PEWN: <br /> N: _ <br /> B L.1 <br /> R <br /> LICENSED CONTRACTORS DECLARATION <br /> i I hereby affirm that i am limnse:d under the provisions of Chapter 9(commencing with Section 7000 of Diy islon <br /> C 3 of the Business and Pr6fissioris'Carle,and my license is in futi farce and ett a <br /> A LipenSe'oLO���i [12� Expiratwn Qate <br /> C gignature <br /> E WORKERS'COMPiENSATION DEC"RATION <br /> I.hereby affirm under venally at perjury one of the following decatarations_ <br /> U .91 have and Will M8rdain'a cefficate of torosent to se-4-insure for warWrs'compensation,as provided for by <br /> S Section 3700 of ttw LabarCode.Nr the pS;1'fprn•lanW of the Work tar which thio permit is isxced. <br /> T 01 have and will rnafntain workers'co <br /> rttpensa0ort InsRltance,05 rlaquyrad by Scion 37011 of the Labor Code, <br /> for the perlrmanre of the work.for which this permit is iswied. MY workers'Compeoration insurance carrier <br /> -arid policy number are-. <br /> H Carrier a Policy Niumw -Le,� <br /> W 0 •1 oar fy that In the perbmvancs of*m work for whkh 04 permit is issued,;stmil not ehsploy any penin in ony mpnnw <br /> so as to become sub 1 to Om wprkvW cvn•+pensatunr lum Vf C,alilotltE21,71d agMe tt►aR 11 stmWld become subjhd to <br /> a the workers'compensation pnw sions of Section 3700 of the Labor Code.I shall forthwith rx+ Wty with those p wAsions• <br /> Date Appricant <br /> wAkNiNGi:Fmwitt=To smusti;woRyeFts,co tapmArm C01 E LACE Is LMLAVwFUL.AND SHALL SUBJECT <br /> AN VdK0YER TO.CREMtNAL PENALTM$ANO 01M FINN UP TO ONF_rls)NORIM THOUSAND DOLLARS <br /> (100,000).IN A0171TION TO IMF COST OF COWF.NSAT*M,LA MAGE$AS PRCMi?ND FOR 11[SECTION 3fas OF <br /> 'THE LABOR COON INTEREST,AND ATTORMUrS 1~Fe& <br /> L <br /> G <br /> E <br /> H <br /> W <br /> R <br /> E <br /> C <br /> Y <br /> C <br /> L <br /> E <br /> P <br /> B <br /> R <br /> i <br />